Safety starts on the ground - Civil Aviation Safety Authority

Safety starts on the ground - Civil Aviation Safety Authority
‘Safety starts ... on the ground’
The importance
import
of ground operations to safety
Nov-Dec 2011
Issue 83
‘Now ssee hear’
Use your radio!
ra
Be heard,
be seen, be safe
Check all current charts and documents BEFORE you fly
Check all available NOTAMs
As a pilot, it is your responsibility to use the correct
frequency and use your radio
‘If in doubt, speak out!’
For further information: www.casa.gov.au/nta
ISSUE NO. 83, Nov-Dec 2011
DIRECTOR OF AVIATION SAFETY, CASA
John McCormick
MANAGER, SAFETY PROMOTION
Gail Sambidge-Mitchell
EDITOR, FLIGHT SAFETY AUSTRALIA
Margo Marchbank
WRITER, FLIGHT SAFETY AUSTRALIA
Robert Wilson
SUB-EDITOR, FLIGHT SAFETY AUSTRALIA
Joanna Pagan
DESIGNER, FLIGHT SAFETY AUSTRALIA
Fiona Scheidel
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replace ERSA, AIP, airworthiness regulatory
documents, manufacturers’ advice, or NOTAMs.
Operational information in Flight Safety Australia
should only be used in conjunction with
current operational documents.
CONTENTS
Features
8
'Safety starts on the ground'
The underrated dangers of aircraft ground handling, and how leading
operators address them.
20 'The heat is on'
Aerial firefighters speak up about the hazards of the job.
24 'Now see hear'
Use your radio - and live to fly another day.
28 'Wind farms and monitoring towers'
Their potential hazards for aviation.
31 'No-one’s playing consequences'
Lessons from a low-key but frightening incident on an international flight
are relevant for anyone who maintains an aircraft.
42 'First Part 145'
Hawker Pacific Airline Support Services is the first organisation in Australia
to be approved under Part 145 of the new maintenance regulations.
58 'The final piece of the puzzle'
The crash of a Vickers Viscount over Botany Bay highlighted the role of
technology in creating safe air travel systems.
62 'When it’s time to go'
The responsibility of evacuating an aircraft quickly and safely falls squarely
on cabin crew.
Regulars
Information contained herein is subject to change.
The views expressed in this publication are those
of the authors, and do not necessarily represent the
views of the Civil Aviation Safety Authority.
2 Air mail
4 Flight bytes–aviation safety news
16 ATC Notes–news from
Airservices Australia
18 Accident reports–International
19 Accident reports–Australian
31 Airworthiness pull-out section
© Copyright 2011, Civil Aviation Safety
Authority Australia.
Copyright for the ATSB and ATC supplements
rests with the Australian Transport Safety Bureau
and Airservices Australia respectively – these
supplements are written, edited and designed
independently of CASA. All requests for permission
to reproduce any articles should be directed to FSA
editorial (see correspondence details above).
34 SDRs
39 Directives
Registered–Print Post: 381667-00644.
46 Close Calls
ISSN 1325-5002.
46 Programmed to deceive
48 He who rides a tiger
50 Almost pressing the grapes
Cover design: Fiona Scheidel
Cover picture: © Fraport AG
This magazine is printed
on paper from sustainably
managed forests and
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Average Net Distribution
October 2010 - March 2011
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Recognised in Australia
through the Australian
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52
66
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71
ATSB supplement
Av Quiz
Calendar
Quiz answers
Flight Safety Australia: winner of the international
Flight Safety Foundation’s 2010 Cecil A. Brownlow
Award for aviation safety journalism.
PA R AV I O N
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MARK KROPP WRITES ON ... SHARING THE
SKIES SAFELY
On Saturday 30 July 2011, I was thermalling a paraglider
at around 3,000 feet just south of Beaudesert in SE
Queensland. A white and yellow low-wing single seat
sports aircraft approached from the south-east and did
two complete 360-degree loops around me at around
100m radius and just above my position, before executing
a barrel roll and heading off to the north-east. General
aviation pilots need to be very aware of what their wake
turbulence (wingtip vortices) will do to our aircraft. I
was in a thermal in rising air, but the pilot was flying in
and out of the thermal and I had no idea where his wake
turbulence was going to end up. Paragliders are very
susceptible to collapses in turbulent air and this pilot’s
foolish antics were putting me at risk. I was too busy
controlling my wing to get away from him to have time to
reach for my VHF and tell him off.
FSA NOV-DEC 2011
2
GA pilots need to be just as aware of what their wake
turbulence is doing as they are of how the turbulence
from larger aircraft would affect them. Paragliders are
highly manoeuvrable, but very slow, and if someone puts
us in a bad position we cannot get out of it quickly. It is
obviously safer to approach us from downwind and below
our position or, better still, just stay right away.
GA pilots: we are not ‘toys’ to be played with out in the
open sky of class G airspace.
“Spidertracks real-time tracking is an extremely
important part of our operational and safety
mangement. Our pilots and clients rely on spidertracks all over Australia and Papua New Guinea.”
Kim Herne - Heliwest
Invest in the safety of your crew and family
Buy a Spider S3 for only USD995 and
pay just USD2 per flying hour
To find out more call 1-800-461-776 or go to
www.spidertracks.com
Several readers expressed
concern following last issue's
article on with the Lake Eyre
broadcast frequency (127.8)
procedures, among them:
Don M, a private pilot
The article concerning the NOTAM
about the temporary area broadcast
frequency in the Lake Eyre region
rang a chord with me because I was
one of those who did not read my
NOTAMs properly and fell into the
trap of broadcasting only on 126.7 as
I approached (and landed at) William
Creek. It wasn't until I discussed the
'quiet' radio with the proprietor of
the local flight charter business that
I realised I had been on the wrong
frequency. He replied, ‘don’t worry, it
happens all the time’.
This small change would highlight the
names of the affected aerodromes
and catch the attention of private
pilots, who are often daunted by
long NOTAMs full of latitudes and
longitudes.
MELBOURNE FIR (YMMM)
CXXXX/11 REVIEW C1193/11
MARREE, WILLIAM CREEK,
LAKE EYRE REGION
TEMPO DISCRETE AREA BCST FREQ
127.8 ESTABLISHED IN LAKE EYRE
REGION
… just a thought.
Peter Nicholls
1. Make it a permanent change.
What is the problem with having
127.8 promulgated as the permanent
frequency for the region?
2. Reword the NOTAM as below
(my changes in blue)
In your article 'Eyre Space Concerns'
I noted in particular the reference to an
Airvan on final approach into William
Creek (WMC) that was 'desperately
trying to make contact with an
aeroplane which had just entered the
runway at WMC’. The aircraft that had
just entered the runway is described
as the 'offending aircraft', because it
backtracked 'without broadcasting on
the correct frequency of 127.8’. The
frequency of 127.8 has to be used
as a consequence of the FIR NOTAM
quoted in the article.
I suggest that the primary causes of
this (chronic) problem are twofold:
1. When NOTAMS for WMC were
sought from NAIPS, the response I
received, at least up until this week,
was 'no current NOTAM'. For that
reason alone it is hardly surprising to
me that pilots use the CTAF for WMC
specified in ERSA when operating
at WMC. The briefing now says, ‘A
NOTAM service is not provided’ for
WMC. That is one way of reducing
the risk of overlooking the required
frequency, but it doesn’t seem to me
to be the best way.
2. The volume of superfluous
chaff in briefing material that has to
be sorted through to find the wheat
substantially increases the risk of
missing something important.
If the correct frequency to be used
when operating at WMC is the one
specified by the NOTAM rather than
ERSA, the answer is a no-brainer.
Surely it is within the capability of
mankind and technology to program
NAIPS to provide the NOTAM when
a location-specific briefing for WMC
(or Marree) is requested through
NAIPS, and to leave out of FIR and HO
briefings to civilian VFR aircraft all the
irrelevant stuff on ADF FLIP and DAH
amendments etc. that constitutes the
bulk of the briefings.
3
AIR MAIL
I visited Lake Eyre at Easter and admit
to being guilty of the same mistake re
the broadcast area frequency. But the
fault is not with me, I believe, because
the need for you to actually raise this
in a magazine article shows there
Although I am a relatively low-hours is a root cause procedural issue that
pilot, I have accrued my 500 hours unfortunately will not be solved by
over a long period and have had a your article.
40+ year career in aviation and ATC,
during which I have sometimes been When you have a current copy of the
responsible for writing and issuing ERSA it seems illogical to have a longstanding NOTAM which contradicts
NOTAMs.
it. You even point to a problem in
After recovering from the initial the process - the fact that the NOTAM
embarrassment of being on the cannot be attached to (for example)
incorrect frequency, I naturally looked William Creek because it is an
up the NOTAM and was surprised to uncertified aerodrome.
find the reference to William Creek
buried at the bottom of it, with the The solution is simple – have the
main subject appearing to be Lake ERSA reflect the current procedures.
Eyre. I wasn't going to Lake Eyre that If/when the lake dries up I’m sure it
day; I was flying to William Creek, so will be easy to go back to the 126.7
I didn't pay it any particular attention. frequency. Why make life complicated
when the solution is so easy?
It seems to me that if this problem
is ongoing and common, there is a
system safety issue here, so it is not
just a matter of telling pilots to read
their NOTAMs, although that is a
good place to start. I have thought
about why I missed the alert in my
read-through and offer a couple of
solutions:
And lastly … Clinton McKenzie
PA R AV I O N
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Mal Wardrop, CASA aviation
safety advisor for the central
region, responds:
FSA NOV-DEC 2011
4
1. The main safety issue identified
back in 2009 was that there were
increasing numbers of sightseeing
aircraft over Lake Eyre broadcasting
on 126.7, rather than on the area
frequency. These broadcasts were
interfering with other aerodromes
with the CTAF 126.7. The first draft
of the CASA instrument left Marree
and William Creek CTAFs on 126.7,
with just the broadcast area on 127.8,
but consultation with local operators
saw the two aerodromes included
in the 127.8 area for situational
awareness purposes. Airservices
creates the NOTAM based on the
CASA instrument. There are standard
formats for NOTAMs, which by the
way are legal documents.
2. Many aerodromes are privately
owned and often require prior
permission to land (PPR). William
Creek is such an aerodrome but it has
been my experience that pilots who
contact the aerodrome operator for
permission usually received additional
friendly advice on matters such as
parking, fuel availability, and even
accommodation. Most importantly,
they are briefed
on the need to use frequency 127.8
at the aerodrome and over Lake Eyre.
This advice is helpful for a safe arrival
and an enjoyable stay.
VALUABLE SAFETY
RESOURCES FROM THE CASA
ONLINE STORE
3. Pilots planning to land at
unfamiliar aerodromes listed in ERSA
should ensure that they make a
careful study of all information listed
in ERSA. Taking only a cursory glance
at the runway direction and length
and the CTAF frequency could result
in the pilot missing vital information
such as Note 1 in the William
Creek and Marree entries. Should
clarification of an ERSA entry or a
NOTAM be required, the pilot should
contact an air services briefing officer
on the numbers listed in ERSA.
Visit www.casa.gov.au/onlinestore
to find safety information products
including posters, DVDs, Z-cards,
charts and booklets on topics
such as flight planning, helicopter
safety, VFR, ageing aircraft, safety
behaviours, situational awareness
and more.
If you have not already explored the
joys of the CASA online store now
is the time to do so! The Safety
Promotion section supports CASA’s
mission to create safe skies for all
by producing a range of informative
resources for aviation professionals
and training organisations.
The products are all free of charge,
but a $15 postage and packing fee
applies to each order, whether for
one or multiple items, so it makes
sense to order more than one item.
PRESSURE RELIEF CUSHIONS
APPROVED FOR USE
Flying can now be more comfortable
for passengers who use special
cushions to protect them from
pressure ulcers/sores. CASA recently
approved the use of pressure relief
cushions in flight, following a recent
complaint from a passenger.
David Villiers, manager, Initial
Airworthiness section, says CASA was
approached by a member of the public
complaining about their treatment
by a regular public transport (RPT)
operator who would not allow the use
of a cushion.
‘Cushions are not currently allowed to
be used during critical flight phases
covering take-off, landing, instrument
approach, flight below 1,000ft, and in
turbulence, as defined by CAR 251,
as this effectively modifies the seat.
‘An inflatable cushion is likely to burst
during high vertical deceleration and
increase loads to the passenger’s
spine.
QUIZ CORRECTION
Thanks to the keenly focused
readers who picked up our mistake
in September-October’s quiz
In question 9 of the SeptemberOctober Flying Ops quiz, the
preamble should read ‘with a
propeller rotating clockwise
from the cockpit’ (as with an
American engine), and not anticlockwise (British engine) as
written.
5
FLIGHT BYTES
‘We have determined that, other
than during take-off and landing, the
cushion may be used inflated and can
also remain inflated during turbulence
as turbulence encountered by aircraft
is never severe enough to activate the
energy-absorbing features of aircraft
‘The passenger, who requires a seats.
pneumatic pressure relief cushion
‘During take-off and landing the
both in their wheelchair and on board
cushion must be deflated but it
the aircraft, asked CASA to clarify
does not have to be removed from
the use of such cushions on aircraft,
the passenger’s seat, as a deflated
and asked for a written determination
cushion is no different from any
from CASA to allow its use for future
form of loose clothing and in any
travel,’ said David.
case, the passenger is restrained by
the aircraft seat belt. ‘CASA will be
making RPT operators aware of this
determination.’
KEEPING ON TRACK WITH CASA
OnTrack is an interactive guide to operating in and around
Australia's controlled airspace.
www.casa.gov.au/ontrack
The program helps you fly safely by allowing you to
preview your flights over unfamiliar terrain before taking
to the air. It demystifies Class D procedures and shows you
how to avoid airspace infringements. Video, pop-up alerts,
location images and animated flight threads take you step
by step into and out of Archerfield, Bankstown, Cairns,
Cambridge, Camden, Jandakot, Launceston, Moorabbin
and Parafield aerodromes, and specific location images
give you a pilot's eye view of vital tracking and approach
points and landmarks.
Sunshine Coast, Tindal, Darwin and Alice Springs
aerodromes are set to be added during 2012.
CASA developed OnTrack with the support of Airservices .
DREAMLINER DOWN UNDER
FSA NOV-DEC 2011
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Boeing’s new 787 is going on tour in Australia. The 50
per cent composite-materials-by-weight, new generation
airliner will come to Sydney for two days from 15
November, before visiting Melbourne.
See the January–February 2012 issue of Flight Safety for
an overview of composites in aviation.
AND JUST ONE MORE AVIATION HIGH …
Noosa District State High School on the Sunshine Coast in
Queensland offers Aviation Studies in Years 11 and 12 as
an O.P. (university entrance) subject.
The school has links with Emerald Free Flying at Caloundra
and Pro Sky Flight Training for flying instruction, as well
as with Cooloola Flying at Gympie and Becker Helicopters
at Sunshine Coast Airport to give students an introduction
to control tower operations, firefighting and airport
administration.
7
FLIGHT BYTES
FSA NOV-DEC 2011
8
and related ground safety are somewhat neglected
areas of aviation safety. The Australian Transport
Safety Bureau (ATSB) released two reports in 2010:
Ground operations occurrences at Australian airports
1998-2008 (report released in June 2010) and
Aircraft loading occurrences 2003-2010 (released in
December 2010). According to these reports, ‘the
aviation industry has been slow to acknowledge the
risks associated with ground operations’.
There is under- or ambiguous reporting of ground
operations issues, some with frightening potential.
‘We can’t underestimate the importance that
ground operations have in overall safe operations,’
explains Will Tootell, CASA’s team leader, technical
operations. Recognising this, 18 months ago,
CASA established a team of ground operations
inspectors to oversee ground operations and drive
consistency and higher standards. Raquel Moran,
based in Sydney, has longstanding experience in
airline ground operations and management, across
international, domestic, regional and GA operations;
David Heilbron, based in Melbourne, joined CASA in
2010, after 12 years ground operations and auditing
experience in domestic and international airlines.
‘Since we started the ground operations role towards
the end of 2010, we’ve been involved in regulatory
service functions which have included the entry
into service of aircraft such as a B767 freighter and
an A330, aircraft operator certificate audits, ramp
surveillance and special investigations relating
to ramp incidents and accidents, load control and
aircraft loading, restraint issues and aircraft damage
from ramp equipment,’ Moran explained.
9
Consistency, or lack of, in ground operations policies
and procedures, is a major issue, according to Joe
Hain, one of CASA’s aerodrome inspectors, whose
main focus is on aerodrome/airport operators. Hain
came to CASA after many years of working with
airlines. Ground handling is an extremely competitive
business, with conflicting pressures from airline
schedulers, airport management and autonomous
ground handling companies.
Add to these the complexity of jurisdiction: are
ground operations an aviation safety issue, or an
OH&S one? In cases of discrepancies relating
to ground operations safety procedures, whose
safety management system will take precedence?
The airline’s? The airport operator’s?
A disturbing example occurred as this issue went
to press. As the Sydney Morning Herald reported
(20 October 2011), an RPT first officer was badly
injured after he was blown from stairs at the back
of a Boeing 737 by the engine thrust from a B747
taxiing close to his plane. Safety experts are
looking into how the 747 came close enough to the
737 to blow over the stairs on which the first officer
was standing. The pilot had been conducting preflight checks on the parked 737.
‘It’s not so much a case of things falling through the
cracks,’ one industry commentator says, ‘as them
falling through into a chasm.’
GROUND SAFETY
While these reports reveal a relatively low incidence
of ground operations issues, and Australia has
not experienced a major aircraft accident due to
a ground-operations occurrence, some industry
insiders say the real figures are a cause for
concern. There is, one writer says, ‘a huge amount
of reluctance within the sector when it comes to
talking about safety and past incidents’.
Regular readers of ground handling trade journals
such as the American-based Ramp Equipment and
Ground Handling International, would acknowledge
that in many aspects of ground handling and ground
safety, European operators are leading the way:
in technology, in work practices and in training.
One such operator, many argue, is Fraport.
FSA NOV-DEC 2011
10
Fraport, the German company that operates Frankfurt
International Airport, Europe’s third busiest airport
after Heathrow (London) and Charles de Gaulle
(Paris), as well as having interests in a number of other
international airports, also has a very successful ground
handling operation. The airport manages 1200 traffic
movements a day, and has a reasonably large footprint
of 2000 hectares.
Bernhard Scholz, Fraport’s executive manager, ground
support equipment, is a passionate advocate for
efficiency and safety in this very busy ground handling
environment. The company has an investment of
approximately €250 million in ground support equipment
(GSE), including de-icing and firefighting equipment.
This equates to around 170,000 items, including 1700
motorised GSE units.
Fraport is very particular in its selection of ground
handling equipment, and operates some of the best in
the world, according to Scholz. Their German, Spanish
and French equipment is chosen for its efficiency and
safety, with Goldhofer pushback tractors just one
example. The Goldfhofer is towbarless, making for
safer, more efficient operations, Scholz says.
Due to the large number of aircraft types, and the size
of today’s airports, logistics require faster and more
flexible aircraft ground handling, to make better use of
the existing infrastructure.
Environmentally conscious towing, with a corresponding
reduction in jet fuel consumption, is also becoming
more important. The towbarless tractor’s faster driving
speed allows up to three times faster pushback than
operations using conventional towbar tractors, and, its
users argue, is much safer.
in a pushback operation has led to a number of ramp
accidents. In one case, for example, quoted in the
August 2011 issue of Ground Handling International,
the use of a poorly-marked towbar, 55cm shorter
than the correct towbar for the pushback of a
Fokker 100 led to a 300mm indentation in the nose
cone of the aircraft.
The pick-up device is the heart of all such towbarless
tractors. During towing, sensors continuously
monitor and control the pick-up device, immediately
displaying any malfunctions to the driver.The
suspension of the pick-up device also ensures that
it can accommodate the movement of the nose-gear,
without inducing additional forces during cornering.
The more controlled, one-person, cab-based
operation of the towbarless tractor, it is argued,
is safer than conventional towbar operations,
reducing the risk of damage to humans and aircraft.
The physical action and coordination required by
the operator to move an aircraft with a towbarless
GROUND SAFETY
Towbarless tractors, as the name suggests, do not
use a towbar. On the towbarless tractor, the nosegear tyre is in the pick-up device, which is located
in the centre of the vehicle. This pick-up device
draws the aircraft onto a platform and lifts it. There
is a direct and firm connection between aircraft and
tractor, so the combination can be moved without
problems at speeds of up to 30km/h. One person can
control the pick-up and release of aircraft, carrying
out all movements from the cab, so a ‘brakeman’ is
no longer necessary.
On the other hand, conventional towbar tractors need
to have a gross weight of approximately 70 tonnes so
they can transmit the tractive force required for large
aircraft, for example, a Boeing 747. Conventional
towbar towing permits a maximum towing speed of
15km/h because of the driving dynamics. The shear
pins on the tow bar avoid excessive tractive and
braking forces being induced in the aircraft. That is
why a ‘brakeman’ must always be in the cockpit to
stop the aircraft safely if a shear pin breaks away.
The main advantage of a towbarless tug is simplicity.
If you eliminate the towbar altogether, you eliminate
the need to have a variety of aircraft type-specific
towbars. Confusion about the correct towbar to use
11
tractor is simpler and easier to learn than one with
a towbar. By connecting the tractor directly to
the aircraft's landing gear—instead of through
a towbar—operators have better control and
responsiveness when manoeuvring. Not only that,
but many towbarless tractors have ergonomically
designed cabins, with seats that can be rotated 180°,
giving the driver the best possible visibility, and with
suspension designed to minimise spinal shock.
However, Flight Safety Australia understands the
situation in Australia is still much the same as in
2004, when Australian safety expert, Geoff Dell,
reported: ‘The penetration of towbarless tractors
into the market has been limited … The industry
culture in many parts of the world continues to
support the notion that a licensed maintenance
technician must be available to react to emergencies
during pushback and engine start, despite there
being no hard evidence.’
Fraport encourage ongoing innovation, and have
won various awards recognising this. Modifications
made to their ladder operations, for example, won
them the 2003 Ground Handling International Ramp
Safety award.
FSA NOV-DEC 2011
12
Fraport have also introduced GPS tracking for their
GSE. This monitors the location, status and use of the
equipment, allowing comprehensive management of
the GSE fleet, including features such as geo-fencing,
access control, engine operation, general vehicle
status, service registration and maintenanceplanning information. A software module displays
all GSE units on the system’s airport map, showing
their current location and operational status.
The GSE units are equipped with on-board units
powered by the GSE’s on-board electric system and
can be linked to other on-board systems. Each onboard unit connects to the central server via GPRS
or Wi-Fi.
The GSE historical operational data and all other
relevant information is saved and is used to evaluate
usage, operating times and distances travelled, as
well as to support efficient GSE maintenance plans.
To increase operational efficiency, the condition of
certain types of GSE can be controlled; the system
monitors and issues warnings about low fuel, high
oil temperature, low battery level or (for example
in the case of high loaders) engine running without
lift operation during a certain period of time. If a
low-fuel warning is generated and forwarded in
real time, the system can automatically generate a
fuelling task.
The system also facilitates increased safety and
security on the apron. The geo-fencing function
means specific areas can be defined as prohibited,
so that warnings are given when specific GSE
units, or GSE in general, enter this prohibited area,
or leave their allocated areas. Geo-fences can be
permanently fixed areas, or set for a limited time
(e.g. on construction sites).
The on-board units can also register movements
and impacts during engine-off times, as well as
controlling vehicle speed and issuing alerts if speed
limits are exceeded. Each vehicle can be registered
to its assigned operator, to prevent unauthorised
use, or to allow further control of its operation.
Airport operators are aware of the twin safety
issues of congestion and excessive GSE speed; the
GPS tracking and controlling capability provides
an alternative to instituting speed limits, with their
accompanying surveillance requirement.
‘Maintenance is a ground safety issue’, Scholz
explains, and all the GSE are on an ongoing annual
maintenance schedule. ‘It’s all computer-based’, he
says, ‘so we have an overview of every screw, and
can see that everything is operable, and which GSE
is due for maintenance.’ This computerised system
is backed by old technology: the hubs of serviceable
GSE are painted bright pink, so that they can be
readily identified on the apron.
But above all, Scholz argues, ‘education is still the
most important part of safety’. Some operators,
trying to cut costs, hire people with no education,
and if these people don’t think, then you have
a problem.
‘It is becoming harder and harder,’ he says, ‘because
from an airline point of view, ground handling is
too expensive, so there are downward pressures
on costs.’
However, Fraport’s fifty-per-cent German-born,
and fifty-per-cent immigrant workforce is ground
handling certified by the German government.
Fraport is strong on training, and has a tiered driver
education program. Level one drivers are qualified to
operate conveyor belts and small tractors; level two
includes equipment such as steps; and level three
is the highest equipment level. Ground handlers
wanting to become drivers have to complete an
accident-free year to qualify for level one. If they do
have an accident, they go back to loading in the belly.
Likewise, there is also a tribunal which adjudicates
on accidents. The evidence in the accident report
is examined, and the employee concerned is
interviewed.
Employees are offered ‘goodies’ - incentives such
as improved conditions, and medical benefits, which
help to ensure that the Fraport ground-handling
workforce, unlike many, is relatively stable. This
workforce retention then has an impact on the
effectiveness of the training program.
One group promoting ground safety in Australia and
New Zealand is the Australasian Aviation Ground
Safety Council (AAGSC), comprising members
from major Australasian airports, ground handling
companies and airlines.
As part of promoting ground safety, the AAGSC
sponsors an annual ground safety award. One of
this year’s entrants is Virgin Tech’s aircraft towing
simulator, which the company developed in response
to several identified training issues.
Engineers and some contractors are required to tow
aircraft as part of their regular work tasks. Towing
occurs at airport terminals during the departure of
aircraft, aircraft relocations, and when transferring
aircraft to and from maintenance facilities.
13
GROUND SAFETY
If a deliberate flouting of the rules caused
the accident, the tribunal, comprising union,
management and safety management members,
meets to determine the penalty or punishment.
This could be the ramp worker losing their ramp
driving licence for six months or a year; losing their
privileges; or going back to training school.
Learning how to tow aircraft safely, and assessing
competence in doing this, have usually been
achieved either by towing freight barrows or other
GSE, or through on-the-job training using actual
aircraft. However, Virgin Tech felt this was not
ideal. Tow training on freight barrows and other
GSE was very unrealistic, and using an aircraft,
while providing real skills to the trainee, brought
significant disadvantage and risk. Spare aircraft for
such training can be difficult to find, and if available,
are often only available at night, when routine
workload is high and visibility reduced. There is also
the risk of damage to the aircraft during the training
session. And finally, most available areas for training
with aircraft are very hazardous: the congestion and
noise of normal airport operations coinciding with
the training session.
FSA NOV-DEC 2011
14
So Lachlan French, Virgin Tech’s Melbourne-based
training manager, decided that a towing simulator
would be the most appropriate solution to minimise
both the risk and the interruption of day-to-day
airport operations. The company considered a
computer-based simulator, but felt this would not
offer the desired real-world experience of a handson towing simulator. Working with the Virgin Tech
GSE leader, French developed the towing simulator,
enabling trainees to become competent in a safe and
controlled environment.
The towing simulator is scaled to the dimensions
of a Boeing 737-800 aircraft, to best simulate the
performance, feel and responses of actually towing
an aircraft.
The towing simulator has the following features:
The towbar connection point is a dual wheel
turntable fitted with audible and visual warning
indicators to alert the trainee when the maximum
aircraft turning angle has been reached.
It can be attached to a tug or other suitable towing
vehicle using a conventional aircraft towbar.
A vertical stabiliser adds realism, and more
importantly, is an indicator for marshalling and
spatial referencing.
As well as being scaled to a Boeing 737-800 the
wheel base and track are designed to the same
ratio as a B737.
The simulator frame can shortened by relocating
two bolts, so that it is easier to transport
and store.
The battery powering the maximum turn angle
warning indicators is recharged using an
on-board 240V charger. This charger can be
substituted with a solar charger if the simulator
is stored out of doors.
A 1000-litre ballast tank is fitted to adjust the axle
weight of the simulator as required.
Following the success of the first towing simulator,
the company is manufacturing a second for use in
their Brisbane hanger.
To ensure a thorough understanding of the operation
of the towing simulator, French and Virgin Tech
training developer, Peter Hancock, developed a
comprehensive training and assessment package, in
three parts:
1. the operation of the various towing tractors and
tugs in the Virgin Australia business.
2. guidance material and exercises for the students
to use with the towing simulator. (The longest
part of the course).
Potential trainees must have a number of licences: a
valid state or territory driver’s licence, a valid airside
driver’s authority, and a radiotelephony licence.
As this issue of Flight Safety Australia went to print,
submissions for the award were being judged.
Results will be published in the January-February
2012 issue of the magazine. Thanks to the AAGSC
and Virgin Tech for permission to use this material.
GROUND SAFETY
3. involves combining all the acquired experience
by performing tows on aircraft under the direct
supervision of an experienced, approved aircraft
tower. Only after successfully performing a
number of tows, under a variety of conditions,
would the student be assessed for competence.
15
ATC
notes
Operations at non-conforming
cruising levels
Conforming (often referred to as standard) cruising levels provide a layer of
safety in all airspace classifications. Deviation from conforming levels erodes
a key system defence, which is why exposure to the increase in risk should be
kept to a minimum.
FSA NOV-DEC 2011
16
0°
EVEN
Thousands
to
FL 280 then
FL 300
FL 320
FL 340
FL 360
FL 380
FL 400
359°
FL 430
etc
180°
ODD
179°
Thousands
to
FL 290 then
FL 310
FL 330
FL 350
FL 370
FL 390
FL 410
FL 450
etc
0°
EVEN
Thousands
PLUS 500
to
FL 185
ODD
179°
Thousands
PLUS 500
to
FL 195
VFR FLIGHT NOT PERMITTED
IN CLASS A AIRSPACE
The latest change places the onus on the pilot
to only request a non-conforming level when
359°
180°
IFR CRUISING
LEVELS
airways system while keeping risk levels as low
as reasonably practicable.
VFR CRUISING
LEVELS
Source: AIP ENR 1.7 – 10,
n recent years there have been numerous
discussions between Airservices, airlines,
pilots, and CASA regarding pilot requests to
operate at non-conforming levels.
I
There have also been multiple incidents in
which non-conforming levels have been found
to be a contributory factor. As a result, both AIP
have amended procedures surrounding nonconforming levels.
(AIP ENR 1.7-6). The pilot must include the
phrase “due operational requirement” when
requesting a non-conforming level. ATC will then
assess a non-conforming level request.
A controller can assign a non-conforming level
require, but is required to continually assess
the suitability of this arrangement and return
the aircraft to conforming levels as soon
DV¬SUDFWLFDEOH
As a pilot, when operating at a non-conforming
level, you should advise ATC as soon as the
operational requirement ceases and you are able
to return to a conforming level.
You can now get the latest Airservices news and updates via our Twitter account:
@AirservicesNews
We will use Twitter to keep you informed about a range of Airservices activities,
including news, updates to our website, the release of new documents and
publications, new safety promotion products, and our attendance at events.
ICAO 2012 flight plan changes
how will this affect you?
Many pilots are already aware ICAO has issued Amendment 1 to the PANS-ATM
4444 provisions for flight planning, involving changes to content and indicators
used in the ICAO flight plan form. Global implementation is planned to commence
from mid-2012.
T
"JSTFSWJDFTJTNBLJOHDIBOHFTUPJUTnJHIU
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control displays to ensure a smooth transition.
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nJHIUQMBOOJOHJOUFSGBDF5IFHFOFSBMBWJBUJPO
DPNNVOJUZDBOFYQFDUTPNFDIBOHFTUPnJHIU
planning requirements as a result.
While there will be less impact on most general
BWJBUJPOPQFSBUPSTUIFDIBOHFTQSJNBSJMZSFMBUFE
UPOPUJmDBUJPOPGBEWBODFETVSWFJMMBODFBOE
OBWJHBUJPODBQBCJMJUJFTTVDIBT1#/FRVJQBHF
will still need to be universally understood.
As we move closer to transition, further
information will be provided in this magazine, AIP
Supplements, the Airservices website and direct
mail to pilots. More information:
The main changes are:
ƒ
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of advanced radio communication and
approach aid equipment/capability in item
BPGUIFnJHIUQMBO
ƒ
Airservices: www.airservicesaustralia.com
ƒ
AIC H08/11 – https://www.
airservicesaustralia.com/publications/current/
sup/a11-h08.pdf
ƒ
ICAO PANS-ATM Doc 4444, 15th Edition –
Amendment 1 http://www2.icao.int/en/FITS/
FITSLibrary/PANS%20ATM%20Amendment.
pdf
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item 10a
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equipment in item 10b including ADS-B and
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bangkok.icao.int/edocs/FPL_Guidance_ver3.
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plan including PBN
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strict rules for content allowed in STS/
indicator in item 18.
17
ATC NOTES
he change is being made to meet the
needs of aircraft with advanced navigation
and communication capabilities. It will also
enable ongoing moves towards automated air
USBGmDNBOBHFNFOU"5.
TZTUFNT5IFDIBOHFT
XJMMIBWFBTJHOJmDBOUFGGFDUPO"JSTFSWJDFT"5.
systems and on major RPT operators.
International Accidents/Incidents 8 August 2011 - 29 September 2011
FSA NOV-DEC 2011
18
Date
Aircraft
Location
Fatalities Damage
8 Aug
Antonov 24RV
Blagoveshchensk Airport, 0
Russia
Written off
Passenger plane (first flight 1976) substantially damaged in a runway
excursion on an en route stop at Blagoveshchensk Airport. All 36
occupants survived.
9 Aug
Antonov 12A
Omsukchan, Russia
11
Written off
Cargo plane (first flight 1963 - the oldest plane of the Russian
commercial airfleet) crashed about 10km from Omsukchan after the
crew reported a fuel leak and an engine fire. No survivors.
15 Aug
Lockheed C-130
Hercules
over Afghanistan
0
Minor
Lockheed Hercules damaged in a mid-air collision with a 170kg AAI
RQ-7 Shadow unmanned aircraft over Afghanistan. The Shadow UAV
struck the Hercules' left wing and crashed, but the Hercules managed
to land safely.
20 Aug
Boeing 737-210C
near Resolute Bay
Airport, Canada
12
Destroyed
Passenger plane (first flight 1975), with 11 passengers and four crew
members on board, destroyed when it flew into terrain while on
approach to Resolute Bay Airport. Weather reported as a 200ft ceiling
with three miles visibility in fog and drizzle. Wind 180 degrees at 10kt.
21 Aug
BAE Hawk
1.6km from Bournemouth 1
Airport, UK
Destroyed
Red Arrows pilot killed when his aircraft crashed into a river
embankment after a flying display at Bournemouth's annual air festival.
28 Aug
Antonov 2R
near Neschadinovskay, 1
Krasnodar region, Russia
Destroyed
The Antonov with two occupants, operating on an illegal crop spraying
flight, crashed and burst into flames during an emergency landing.
2 Sept
Cessna 208B
Grand Caravan and
Cessna T207A Turbo
Stationair 7
14km north of Nightmute, 1
Alaska, USA
Destroyed
Two planes being operated under VFR collided in mid-air. The 208B
crashed, killing the pilot, and the 207 made a forced landing, which the
pilot survived. The two pilots had a close personal relationship and had
been talking on a discrete radio frequency and flying their planes very
close together before the impact.
2 Sept
CASA C-212 Aviocar
off Isla Robinsón Crusoe
Airport, Chile
21
Destroyed
Chilean Air Force transport plane (first flight 1994) destroyed when it
crashed into the sea on approach to the airport, killing all aboard. The
passengers included a crew from Televisión Nacional de Chile and NGO
and Air Force personnel en route to see the progress of relief activities
after the 2010 earthquake.
6 Sept
Swearingen
SA.227BC Metro III
8km NW of Trinidad
Airport, Bolivia
8
Destroyed
Passenger plane (first flight 1992) crashed into jungle while on approach
to runway 14, killing the two crew and six of seven passengers. The
wreckage and the sole survivor were not found until 8 September.
7 Sept
Yakovlev 42D
2km from YaroslavlTunosha Airport, Russia
44
Destroyed
Passenger plane (first flight 1993) crashed into the Volga River during
initial climb. On it were members of the Lokomotiv Yaroslavl ice hockey
team. It was reported that all the engines were working until the
aircraft ran off the runway onto grass, barely climbed and then collided
with obstacles. The stabiliser was set to 8.7 degrees nose up and the
flaps were at 20 degrees before take-off.
9 Sept
Cessna 208B Grand
Caravan 1
near Tangma, Yahukimo
District, Indonesia
2
Written off
Aircraft carrying four drums of diesel fuel and some goods to a remote
airstrip crashed in mountainous terrain.
14 Sept
Embraer 120ER
Brasilia
Huambo Airport, Angola 26 or 30
Written off
An Angolan Air Force aircraft crashed on take-off, broke in two and
caught fire. Conflicting media reports say that 26 or 30 occupants,
including three army generals, were killed. Six occupants survived.
16 Sept
P-51 Mustang
Reno, Nevada, USA
11
Destroyed
The P-51 fighter, taking part in the National Championship Air Races,
suddenly pitched upwards, rolled, and nose-dived into a section of
seats, killing the pilot and ten spectators and injuring at least 69 more.
Witnesses said that the trim tab appeared to fall off the tail.
20 Sept
Pitts Model 12
Wheeler Downtown
Airport, Kansas, USA
1
Destroyed
The custom-built biplane nose-dived into the ground adjacent to one
of the runways and burst into flames, after failing to pull up from a
downward spiral during aerobatic manouevres.
20 Sept
Beechcraft 99A
near Milot, Haiti
3
Destroyed
Passenger aircraft (first flight 1969) crashed in a flooded sugar cane field
in poor weather with heavy rain.
22 Sept
DHC-6 Twin Otter
300
Yellowknife, Northwest
Territories, Canada
2
Written off
Float plane (first flight 1973) sustained substantial damage when it
crashed in a street next to Yellowknife Waterdome, killing both pilots.
23 Sept
DHC-3T Texas
Turbine Otter
near Heitman Lake,
Alaska, USA
1
Written off
Aircraft crashed on approach to Kodiak Airport. The pilot was killed and
the two passengers seriously injured.
25 Sept
Beechcraft 1900D
8km SSE of Kathmandu- 19
Tribhuvan Airport, Nepal
Written off
The Beech 1900 (first flight 1997) was on the base leg of the approach
following a sightseeing flight when it crashed into the roof of a house in
a village about 3nm short of the runway threshold in rain and dense fog.
29 Sept
CASA/Nurtanio NC212 Aviocar 200
near Bohorok, Sumatra
Written off
Aircraft (first flight 1989) crashed in a forest. Rescuers unable to reach
the site until 1 October because of poor visibility. No survivors.
18
Description
Notes: compiled from information supplied by the Aviation Safety Network (see www.aviation-safety.net/database/) and reproduced with permission. While every effort is made to ensure accuracy,
neither the Aviation Safety Network nor Flight Safety Australia make any representations about its accuracy, as information is based on preliminary reports only. For further information refer to final
reports of the relevant official aircraft accident investigation organisation. Information on injuries is not always available.
Australian Accidents/Incidents 4 August 2011 - 29 September 2011
Date
Aircraft
Cessna 172B
Location
Injuries
Kondinin (ALA), WA Nil
Damage
Serious
15 Aug
Cessna 177
Cardinal
South Grafton
(ALA), NSW
Nil
Serious
15 Aug
Piper PA-28-180
Archer
Horsham
Aerodrome, N M
40km, Vic
Cessna 210N
Kununurra
Centurion
Aerodrome, WA
Aerospatiale
Marree (ALA), N M
AS.355F2 Squirrel 145m, SA
Auster J5B
Broken Hill
Aerodrome, 359°
M 17km, NSW
Cessna U206G
William Creek
(ALA), 040° M
117km (Lake Eyre),
SA
Air Tractor
Pearce Aerodrome,
AT-802
002° M 74km, WA
Boeing 737-8FE Christchurch
International, NZ
RolladenKingaroy
Schneider
Aerodrome, Qld
Flugzeugbau
LS8-18
Robinson R44 II Plutonic Gold Mine
Aerodrome, 322°
M 63km, WA
Aerospatiale
Rockhampton
AS.350BA
Aerodrome, 341° M
Squirrel
98km, Qld
Fatal
Destroyed
Minor
Serious
Fatal
Serious
Nil
Serious
Nil
Serious
Nil
Serious
Nil
Serious
Nil
Serious
Fatal
Serious
It was reported that the helicopter collided with terrain.
The investigation is continuing.
Fatal
Serious
11 Sept
Air Tractor AT802A
Nil
Serious
12 Sept
Robinson R44
Emerald
Aerodrome, 097°
M 37Km, Qld
McArthur River
Mine Aerodrome,
228° M 45km, NT
Nil
Serious
26 Sept
Cessna 152
near Bankstown
Aerodrome, NSW
Nil
Serious
29 Sept
Robinson R22
Beta
Maningrida
Aerodrome, 189°
M 62km, NT
Nil
Serious
A passenger reported that the helicopter crashed while on
communications tower maintenance ops. The police advised two of the
three people on board were dead and one was injured. The investigation
is continuing.
During take-off, the aircraft struck an Australian bustard. The impact
damaged the wing, causing a loss of control, and resulted in the left wing
striking a fence.
During cruise, the engine fire light illuminated and the oil pressure dropped
to zero. The pilot conducted a precautionary landing and noticed flames
emanating from the engine after landing. The subsequent fire caused
serious damage. The investigation is continuing.
During initial climb, the aircraft's engine failed and the crew conducted
a forced landing in a paddock. The aircraft flipped over and came to rest
inverted. The investigation is continuing.
During aerial mustering, the helicopter's tail rotor collided with a tree and
the helicopter landed heavily. The investigation is continuing.
04 Aug
18 Aug
18 Aug
21 Aug
23 Aug
26 Aug
01 Sept
02 Sept
08 Sept
On approach to the aerodrome the aircraft landed short of the runway and
was damaged. The investigation is continuing.
The helicopter collided with terrain. The pilot and two passengers were
fatally injured. The investigation is continuing.
During landing flare, the aircraft drifted off the runway centreline, and
the pilot applied power for a go-around. The aircraft stalled and the main
landing gear collapsed.
During a scenic flight, the engine lost power. The pilot and five
passengers were not injured in the resulting forced landing.
The investigation is continuing.
During aerial spraying, the aircraft struck a powerline, and then the
ground. The investigation is continuing.
While taxiing for take-off, the aircraft's wing tip collided with the
horizontal stabiliser of a parked aircraft.
Before touch down, the left wing contacted the glider strip markings,
resulting in the aircraft striking the ground.
Text courtesy of the Australian Transport Safety Bureau (ATSB). Disclaimer – information on accidents is the result of a cooperative effort between the ATSB and the Australian aviation industry.
Data quality and consistency depend on the efforts of industry where no follow-up action is undertaken by the ATSB. The ATSB accepts no liability for any loss or damage suffered by any person or
corporation resulting from the use of these data. Please note that descriptions are based on preliminary reports, and should not be interpreted as findings by the ATSB. The data do not include sports
aviation accidents.
19
ACCIDENTS/INCIDENTS
03 Sept
Description
During landing roll, the aircraft was affected by a wind gust. The pilot
could not maintain directional control and the aircraft veered off the
runway and came to rest in low scrub.
On the base leg of the circuit, the aircraft's engine failed and the pilot
conducted a forced landing. The aircraft landed short of the runway and
collided with a drainage channel. The investigation is continuing.
The aircraft collided with terrain. The three occupants were fatally injured.
The investigation is continuing
FSA NOV-DEC 2011
20
JRM-3 Martin Mars tanker flanked by an S-76. Photo courtesy of Coulson Flying Tankers, British Columbia
As another bushfire season approaches, so does the
question of how to safely fight fires from the air. Training,
fatigue, and the issue of who should have responsibility
for managing these issues are the questions aerial
firefighters and state bushfire agencies are wrestling with.
Some are now calling for the role of firefighting pilot to be
recognised with formal training and qualifications.
Finding the right pilot, with the best combination of
experience, attitude and skill is a challenge in any flying
operation but, particularly so in aerial firefighting, John
McDermott, chief pilot of McDermott Aviation, told
this year’s Australian Aerial Firefighting Conference in
Melbourne.
‘Aviation skills are certainly not reflected by hours.
Skills and attitude are hard to come by in combination,
especially as a ready-made firebombing pilot,’ he said.
Even experienced agricultural pilots can find the transition
to the smoke and turbulence-filled intensity of firefighting
operations a challenge.
‘You might have a pilot whose career has been spraying
cotton on flat land. They’re
experts at it, but if you put them
in the hills, with a heavy load,
it’s a totally different game,’
McDermott said.
Maryanne Carmichael, NSW Rural Fire Service (NSW
RFS) manager of aviation, said: ‘Collectively, we’ve got a
challenge in how we maintain our pilot numbers and get
new pilots through.’
Barry Foster, chief pilot of Woorayl Air Services told the
conference, ‘I really think we need a rating. If it goes
through the (state firefighting) agencies there will be all
sorts of different competencies wanted. We need one
federal rating.’
McDermott said: ‘I think the way to do it for the agencies
is to have an approved training process that leads to a
certain standard.’
‘If we had an aerial firefighting rating, similar to an
agricultural rating, it would be a big step in agencies
feeling comfortable about what standard of pilots they
were getting.’
‘We also know we’re not going to keep all the pilots
ourselves – some of them will go back into the pilot pool,
but we accept that, because we hire some pilots from the
pool as well.’
McDermott said he believed in taking less-experienced
pilots and nursing them through. ‘During that process
you can also develop the right attitude: ‘doing the job in a
professional way and going home every night”.
‘With a rating, it would be feasible to put newly rated pilots
on grassfires for their first 100 hours of firefighting. That
could be a means of progressing people. For helicopters,
command and supervision works well, but that depends
on the type you’re flying. And that’s something agencies
might have to accept – that (Bell) 212s might have to
reduce their load by the weight of a supervising pilot.’
21
THE HEAT IS ON
‘In the old days there used to be
fixed-wing top dressing in the
hills, but that’s all gone now. You
can get pilots with 10,000 hours
experience, all low level, all
precision, but flying up a deadend valley in a heavy aeroplane
is new to them. There’s a whole
different set of skills, that, to be
honest, you don’t get in straight
and level flying in open country.’
For now, the burden of training and of setting flying
standards falls on aerial firefighting contractors
themselves. According to Foster, ‘we offer full-time
employment and we put a lot of training into our
employees.
Photo courtesy of Coulson Flying Tankers
‘One of the major issues we saw in the 2008-09 season
was pilot fatigue,’ NSW Rural Fire Service superintendent,
Keith MacKay, told the conference.
Part of the challenge in managing fatigue, Mackay said
was the long list of organisations and regulations claiming
jurisdiction over the firefighting workplace. These
include the RFS Act and Regulations 1997, WorkCover,
the Environmental Protection Authority, the Dangerous
Goods Act, International Civil Aviation Organization
(ICAO) regulations, the Civil Aviation Act and Regulations
1988, and Airservices Australia, which manages airspace.
Fatigue was covered by CAO 48 and CASR Part 137, as
well as by the fatigue management system adhered to by
individual operators.
NSW RFS 2009–2010 seasonal overview
The result was confusion, Mackay argued, with pilots
covered by one set of regulations being allowed to fly for
14 hours a day, and others restricted to 12 or 10 hours
of duty.
At the other end of the scale, in many cases there was
failure to address the RFS requirements. ‘In some cases
there are also failures to address legislative requirements,’
he told the conference.
Mackay made the point that firefighters were not aviators
by background or training. ‘We’re not aircraft operators,
yet we’re being asked to be more and more involved in
monitoring that industry,’ Mackay said.
‘There’s a huge variation across the country in standards
and practices in occupational health and safety.’
‘We saw it come through on paperwork we were receiving
that some pilots were doing work for two companies, and
not really being monitored correctly.’
‘We have to break down all these processes into a
common message - that we’re managing fatigue.’
FSA NOV-DEC 2011
22
Documentation and consistent procedures were the
foundation of safety, Ogden, a former naval officer,
helicopter pilot and safety specialist, said.
‘We live in a systems world. You can’t deny that. Get used
to it, or the reality is you will likely be out of business.’
Mackay proposed that legislation be harmonised, or
replaced, for firefighting:
Operators who had adopted the systems approach and
were using it to continually improve their operations were
also enjoying the benefits of contracts with mining, oil
and gas companies, he said.
‘That is, that we as firefighters are only allowed to work
12 hours in a shift. By adopting this, all RFS personnel
would automatically understand how to manage pilots
and their fatigue.’
‘I see this in much of the oil and gas business and the
minerals business. If you’re not capable of operating to
their standards, it really is a case of don’t bother tendering
as they’re not interested.’
Mark Ogden, aviation consultant to the NSW Rural Fire
Service, said there was a large variation in standards
among aerial firefighters.
‘The variation between operators is immense. The larger
operators are systems-based and their documentation is
good,’ he said.
The NSW RFS has developed a series of risk-based
standards, making its requirements clear to aerial
firefighting operators. These allow an operator to provide
an alternative means of compliance.
Ogden said the winch standard drawn up in 2008, and
revised in 2010, had found general acceptance in the aerial
firefighting industry. A draft fuel supply standard will be
available for industry comment soon, while bombing and
observation standards are planned.
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23
None of these technologies is new: Los Angeles County Fire
Department first used night vision goggles in helicopters
in 1974; thermal-imaging cameras have been around
since the 1990s; and military laser targeting systems
for aircraft were developed in 1981. But using them in
combination is producing a new, safe and effective way to
fight fires, operators involved in the trial say.
Veteran US aerial firefighter Dennis Hulbert described the
system to the Australian Aerial Firefighting Conference in
Melbourne this year.
A controller at altitude in a Sikorsky S-76 uses a forwardlooking infrared (FLIR) to discover hotspots that might be
hidden from the naked eye by smoke. The controller in
the S-76 uses a gimbal-mounted laser designator, guiding
an S-61 firefighting helicopter to the best place to drop
its fire retardant. The S-61 pilot is able to see the laser
dot, which shows up brightly in third-generation night
vision goggles. There is no longer the ambiguity that
comes with verbal descriptions of the drop point over the
radio network.
‘In southern California you’ve got about 30 aircraft on a
fire: your rotary-wings down low, your tanker orbit and
your tanker drops,’ he said.
‘There’s a lot of communication and many missed
opportunities for drops … you may drop somewhere that’s
less efficient simply because there’s no other opportunity.
At night you don’t have to worry about that because there
are fewer aircraft. It creates an easier environment to
work in. There’s also less wind, less of a smoke column
at night.
‘You get better efficiency: instead of collecting from
your water source, going into an orbit, and waiting,
you’re able to fly straight to your drop point.
‘You’re able to transit direct to the fire - you’ve got a
sterile radio environment because the target description
is done by the laser. The pilots know exactly where to go,’
Coulson explained.
Hulbert told the conference that the night vision goggle,
thermal imaging and laser guidance operation was
feasible, effective from a wildfire operations standpoint,
and could prove valuable in delivering water safely to the
fire during the night when fire behaviour is less volatile.
THE HEAT IS ON
American firefighters are taking their efforts around the
clock, using infrared cameras, night vision goggles and
laser pointers to keep up the pressure on wildfires after
the sun has gone down.
Britton Coulson, of Coulson Aircrane, the operator of the
helicopters in the trial, said laser-guided night flying was
often less stressful, and potentially safer, than daytime
operations.
FSA NOV-DEC 2011
24
Now see hear
Carrying a radio and
using it is a pilot’s
responsibility – as
is knowing which
frequency to use.
It really is that simple.
There was a time when Flight Service used
to advise VFR pilots when they needed to
change frequencies, but those days are
gone. Today’s VFR pilots are expected to
know when to change frequency and are
required to use judgment, professionalism
and common sense in managing frequency
changes. It’s called airmanship.
It is true that pilots have to deal with a
communication system that can be difficult
to understand. This may be especially true if
the pilot only flies occasionally or takes a trip
into unfamiliar territory. The letters page in
this issue of Flight Safety Australia has a range
of responses to the previous issue’s story on
Lake Eyre frequency management. Many
make the reasonable point that NOTAMs are
far from reader-friendly documents. They
are full of abbreviations and potentially
misleading acronyms that date from the days
when NOTAMS were transmitted in Morse
code. But the NOTAM format is set by ICAO
standards and is not likely to change soon.
CASA aviation safety advisor for South
Australia, Mal Wardrop, outlines how the
issue arose: ‘In 2009, the local operators at
William Creek and Marree voiced concerns to
CASA about frequency congestion over Lake
Eyre on 126.7.
The status of the William Creek and Marree
aerodromes complicated the picture, Wardrop
says. ‘This NOTAM had to be issued as an
flight information region (FIR) NOTAM rather
than one attached to William Creek and/or
Marree, as these are uncertified aerodromes
and as such do not have an AVFAX code
in ERSA.
‘Pilots jump on to the NAIPS web site and
request ‘location’ NOTAMs but neglect to
select ‘FIR NOTAMs’ and therefore are not
aware of the special broadcast area 127.8.
They make all their radio broadcasts on
the ERSA frequency of 126.7, resulting in
traffic conflicts between aircraft on the
correct frequency and those on the incorrect
frequency. I experienced this problem at
William Creek in May this year when we were
filming up there.’
Without radio, pilots must rely on unalertedsee-and-avoid. But this is fundamentally
difficult because it is at the limits of human
visual performance, even for the sharpesteyed of pilots.
In all cases, an aircraft on a collision course
appears as a stationary target to the pilot
and may not even be easily visible until
a few seconds before impact. Even if an
approaching aircraft has been seen, there
is no guarantee that evasive action will
be successful.
25
NOW SEE HEAR
Recent incidents around Australia, and
particularly in the vicinity of Lake Eyre and
other hotspots suggest that some pilots are
not up to scratch in this area of airmanship.
A series of separation and other scares has
reinforced the need for pilots to obtain and
use up-to-date en-route charts. Pilots should
always follow correct radio procedures and
prepare thoroughly for all flights by checking
ERSA and NOTAMs for frequency updates
and other vital information.
onal
‘We raised these concerns at the Regional
Airspace
and
Procedures
Advisory
Committee (RAPAC), and as a result CASA
issued a legislative instrument establishing a
special broadcast area on 127.8 for an area
of approximately 120 nautical miles square,
centred on Lake Eyre and including the
aerodromes of William Creek and Marree.
This allowed Airservices to issue a NOTAM to
advise pilots visiting the Lake Eyre region.
The status of the
William Creek and
Marree aerodromes
complicated the
picture ... this
NOTAM had to be
issued as an flight
information region
(FIR) NOTAM rather
than one attached
to William Creek
and/or Marree, as
these are uncertified
aerodromes and as
such do not have an
AVFAX code in ERSA
Recognising and responding to a collision
threat does not happen instantly; and the
wrong evasive manoeuvre may increase the
chance of a collision.
Be heard, be seen, be
Watch and listen
Cockpit workload and other factors can
reduce the time pilots spend in traffic scans.
FSA NOV-DEC 2011
26
The view from most cockpits is frequently
compromised by obstructions such as
window pillars, and the physical limitations
of the human eye mean that even regular and
thorough visual scanning will not guarantee
that other aircraft will be seen.
Reassuringly, information from air-ground
radio services, your transponder and
broadcasts on the CTAF has been shown
to increase your chance of detecting other
aircraft in your vicinity by a factor of eight.
However, whether you fly into non-towered or
towered aerodromes, maintaining a vigilant
lookout at all times is important—you cannot
rely solely on your radio.
A modern gadget that can make missing
a frequency change less dangerous than
it would otherwise be is a dual-monitoring
radio that can listen in to channels other
than the one it is broadcasting on. Some
modern radios offer this feature. There is
good reason to take the advice of a certain
Stetson-wearing television personality and
‘do yourself a favour’ by upgrading your
old radio.
Australian Transport Safety Bureau (ATSB)
reports say that the most common airspace
use and operational-related occurrence types
at non-towered aerodromes are related to
communication breakdowns, radio failures,
relying on the radio as a substitute for
effective visual lookout, misunderstandings,
or insufficient communication between pilots
(388 of 709 occurrences between 2003 and
2008, and 148 of 222 between September
2010 and August 2011). Many of these led to
reduced situational awareness of the pilot,
with consequent separation issues or actual
conflicts between aircraft.
Communication issues accounted for 38 per
cent of all information errors and 31 per
cent of all action errors in these situations.
In almost a third of them it was known (or
likely) that the pilot was operating within the
vicinity (10nm) of a non-towered aerodrome
(a towered aerodrome becomes a nontowered aerodrome after ATC hours) but
not monitoring the CTAF effectively. In 146
occurrences the pilots did not even have their
radio tuned to the correct CTAF.
Airspace use and operations problems are
most common in the vicinity of the busiest
non-towered aerodromes where radio
carriage is required – Newcastle, Avalon,
Geraldton, Broome, Port Macquarie, Dubbo,
Mildura and Wagga Wagga – but are fairly
evenly distributed across other aerodromes
and aircraft landing areas of various sizes,
locations and activity levels.
There is really no reason to fly without a radio,
even in the unpopulated areas where it is still
allowed. Even the smallest owner-built aircraft
can have an aircraft band hand-held radio
with a headset. (Paragliders use just such a
radio set-up.) Without a radio, see-and-avoid –
that could more accurately be called ‘maybesee-and-with-any-luck-avoid’–is a pilot’s only
defence against a close encounter of the most
unpleasant kind.
Reassuringly,
information from
air-ground radio
services, your
transponder and
broadcasts on the
CTAF has been
shown to increase
your chance of
detecting other
aircraft in your
vicinity by a
factor of eight
Be heard, be seen, be safe!
Alerted see-and-avoid 101
Broadcast your intentions:
Maintain a lookout for other aircraft at all times.
before or during taxiing
immediately before entering a runway
inbound 10nm or earlier from an aerodrome
immediately before joining the circuit
on a straight-in approach, on final, by 3nm
from the threshold
on a base-join approach, before joining on base
on entering the aerodrome vicinity of a
non-towered aerodrome, where you intend
to fly through the vicinity, but not land.
Minimise non-essential chat.
It is a false economy to try to avoid landing
fees by sneaking quietly into an aerodrome.
It will cost much more to clean up the mess
if you crash.
t TXJUDIFEPO
t POUIFDPSSFDUGSFRVFODZHFUJOUPUIFIBCJUPG
listening for the beepback)
t DBOCFIFBSENPNFOUBSJMZEJTBCMFUIFTRVFMDI
when setting up the radio to check that the
volume is set and the headset is connected)
t JTUSBOTNJUUJOHNPOJUPSZPVSSBEJPJGJUIBTB
transmit indication, or do a radio check with
someone nearby).
Adhere to all published procedures.
Make all the standard broadcasts, using the ICAO
phonetic alphabet, even if you think there is no
nearby traffic.
27
Concentrate while making radio calls. Do not allow
yourself to be distracted by passengers, your mobile
phone or your GPS.
Give others the opportunity to use radio-alerted seeand-avoid by making all the standard broadcasts
within 10nm of a non-towered aerodrome.
Use standard procedures at all non-towered
aerodromes, unless otherwise stated in the ERSA
or NOTAM.
Be aware that any radio-equipped aircraft could be
conducting straight-in approaches at non-towered
aerodromes.
Avoid overflying aerodromes where possible, and
maintain situational awareness of their inbound and
outbound routes.
Use all your systems to tell others where you are
and where you are going.
If in doubt, speak out! It is
much better to ask for help
than to end up in trouble.
th
tro
NOW SEE HEAR
Always check ERSA, NOTAMs, route charts
and the weather before you fly.
Check that your radio is:
WIND FARMS AND WIND
MONITORING TOWERS
Keith Tonkin, aviation project consultant, and
aviation student, Gabby O'Brien, write on the impact
of wind farms on aviation
Australia has a significant potential for wind energy generation.
We have both an expansive wind resource, and a growing political
commitment to the development of renewable energy sources.
Increasingly, for pilots navigating the Australian skies, wind farms
will become a recognisable feature of the landscape. While this may
break the monotony of a long flight at 38,000ft, it has far greater
consequences for those who fly professionally below 500ft.
28
As part of a risk assessment of the effect of wind farms on aviation
safety, Aviation Projects recently sponsored research by university
aviation student Gabby O’Brien. The study reviewed worldwide
aviation accidents associated with wind farms to identify problematic
issues and to form conclusions about the likelihood of accidents
arising from the hazards posed by wind farms.
FSA NOV-DEC 2011
It was found that wind farms create four types of hazards to aviators:
the potential for collision with a wind turbine
the potential for collision with a wind monitoring tower (WMT)
the potential for controlled flight into terrain (CFIT) as a result
of harsh manoeuvring to avoid collision with a turbine
the effect on operating crew of additional planning time,
additional airborne workload or imposition of operational
procedures or restrictions.
WIND TURBINES
Wind turbines are typically located in rural Australia. They can reach
heights of over 150m (492ft) at the top of the blade tip; some are
currently planned to reach heights of 175m (574ft). These obstacles
are highly visible during the day due to their white/off-white or pale
grey marking.
Where air traffic is likely to be funnelled through a gap or area of lower terrain due to low
cloud, it should be remembered that wind turbines are usually located on the tops of hills
and therefore clear of low-level escape routes.
continued on page 44
WIND MONITORING TOWERS
Wind monitoring towers collect wind data by elevating anemometers
some 60–90m (197–295ft) into the air. The towers however, are
constructed of low-visibility galvanised metal and are anchored to the
ground with near-invisible guy wires. They can be in place for a number
of years before wind turbines are erected on a wind farm site.
WORLDWIDE ACCIDENTS/INCIDENTS
The study analysed aviation accidents and incidents recorded since 2000.
The eight cases all occurred during day operations in Canada, France and
the USA, and include:
1. VFR aircraft struck by wind turbine blades. In this case, the
accident occurred during the day in conditions of low cloud (cloud
base estimated to be between 50m (164ft) and 100m (328ft))
and significantly reduced visibility (estimated to be between
400m and 800m) in fog. The turbine was 120m (393ft) AGL high.
Incredibly, the aircraft was struck twice (once on each wing tip)
by separate wind turbines, but landed safely. The photos below
show the damage caused to the aircraft and a plot of the aircraft
track through the wind farm, which was clearly indicated on the
aeronautical chart used by the pilot.
Wind turbine at Oaklands Hill Wind Farm, Victoria
29
2. Fatal loss of control of a VFR aircraft while manoeuvring
around wind turbines (CFIT)
3. Fatal flipping of an idling helicopter due to excessive
tailwind gusts
WIND FARMS
4. Fatal power line strike during animal control culling
5. Private flight fatally collided with a WMT
6. Aerial agricultural aircraft fatally collided with a WMT
7. Aerial agricultural aircraft collided with a WMT
(see photo below right)
8. Aerial agricultural aircraft fatally collided with a WMT.
Wind monitoring tower at Oaklands Hill
Wind Farm, Victoria
Damaged VFR aircraft from blade strike and flight path (Source: BEA)
Damaged Air Tractor after WMT collision
(source: Transport Canada)
Tool control at a glance
Organisation
t5PPMUSBZToNPSFUIBOQBDLBHJOH
BCVJMUJOTUPSBHFTZTUFN
t4UBOEBSEGPBNLJUToBMMUIFNBUFSJBMT
SJBMTT
BOEUPPMTJOBOFBTZUPVTFLJU
Visibility
FSA NOV-DEC 2011
30
t$PMPVSDPOUSPMoIJHIWJTJCJMJUZ
DPMPVSTGPSTQFDJBMOFFET
t8BMMNPVOUFEUPPMDPOUSPMCPBSET
oTUBOEBSEBOEDVTUPNUPNFFU
ZPVSOFFET
t1SPGSFTTJPOBMMZFOHJOFFSFEGPBN
DVUMBZPVUT
Security
t5PPMDIJUToDBSEBOESFBEFSTZTUFN
t1PDLFUCBEHFToNBSLBOEJEFOUJGZGPBNLJUT
t5SVF'JU7JSUVBM*OWFOUPSZoDPNQVUFSBJEFE
UPPMMBZPVUT
t,FZMFTTDPOUSPMoDBSETOPULFZToGPSCFUUFS
TFDVSJUZBOEDPOUSPM
Trackability
t-BTFSUPPMFOHSBWJOHoUPNBUDI
ZPVSJEFOUJåDBUJPOTZTUFN
t4QFDJBMJTFELJUToCPYFTUPCBHTUP
NBUDIZPVSOFFET
Accountability
t#BSDPEFSFBEFSToCFUUFSBDDFTTDPOUSPM
t5VSOLFZMJTUTUPMBZPVUToDPNQVUFS
BTTJTUFEGPSTQFFEBOEBDDVSBDZ
t4PGUXBSFDPOUSPMBOESFQPSUJOHoUIF
VMUJNBUFPODPOUSPMBOESFDPSELFFQJOH
Tool Control System
Phone: 1800 811 480
Web: www.snapontools.com.au/industrial
PULL-OUT SECTION
Nobody’s playing consequences
The arrival of QF2 at Bangkok Suvarnabhumi
Airport on 7 January 2008 will probably never
make those melodramatic but compelling air
crash TV programs. That’s because, on the
surface, not much happened. But it was far
from an innocuous event.
Late last year the Australian Transport Safety
Bureau issued a report into the incident. For
anyone with even a passing knowledge of
aviation safety its 99 pages are as horrifying
as anything by Stephen King.
The Boeing 747-400 was at flight level 210 on
descent into Bangkok Airport when the cabin
service manager told the pilots about a large
water leak in the forward galley.
The first indication of electrical trouble came
two minutes later: a bus control unit status
message on the engine indicating, and a crew
alerting system (EICAS) display.
AIRWORTHINESS
A close call for a Qantas long-haul
flight has lessons for anyone who
maintains an aircraft. The tiniest
things can have enormous results,
sometimes many years later, write
Roger Alder and Robert Wilson.
31
Location of galley and main equipment centre
Source: ATSB
Seven minutes after that, as the aircraft was descending through
10,000ft for a landing at Bangkok, came the first of a cascade of
system failures.
In rapid succession three of the four alternating current (AC) buses
lost power, the auto-throttle disconnected, the autopilot disengaged,
several fuel pumps ceased operating, the weather radar shut down,
the cabin air conditioning and pressurisation systems failed and the
first officer’s electronic flight instrument system (EFIS) displays went
blank. There were between three and five pages of messages on the
EICAS display, although its lower screen had also gone blank.
It was later found that most of the 747’s electrically powered systems
had stopped working because three of the four generator control units
that managed the AC buses had failed.
‘This goes with this goes with that’ ...
PULL-OUT SECTION
It’s a phrase any engineer modifying a system should
keep in mind as they contemplate making a change,
however slight.
FSA NOV-DEC 2011
32
(They were automatically shut down as
a result of internal faults.) The systems
that still worked were running on power
from the fourth AC bus, or on emergency
battery power. Because the electrical bus tie
breakers for buses 1, 2 and 3 had been left
disconnected by the shut down, the fourth
bus was unable to transfer power to them.
Similarly, the generator control breakers
were disconnected, cutting the three dead
buses off from their respective engine-driven
generators.
The direct current (DC) buses were able to be
powered by DC bus 4, which was powered by
a transformer/rectifier linked to AC bus 4.
The aircraft’s systems that could take power
from the standby bus, battery buses, AC
bus 4, or the DC buses still worked, although
some of these were now operating in a
degraded mode. All aircraft systems powered
through the other AC buses were unavailable.
The auxiliary power unit, the so-called ‘fifth
engine’ that powers electrical systems when
the aircraft is on the ground, could not be
started in flight. The aircraft landed 21
minutes after the first electrical failure, with
about 16 minutes of assured battery time
remaining.
The crew and passengers were lucky. There
were several significant factors strongly in
their favour: it was daylight, the skies were
clear with light winds, and the aircraft was
not only close to its destination airport, it was
first in the queue to land.
One chilling detail is that the same aircraft
had been on an Antarctic charter trip a week
earlier. It doesn’t take a particularly vivid
imagination to consider what would have
happened if the same sequence of failures
had occurred over an icecap at the bottom
of the world.
The ATSB report pulls no punches: ‘Had the
event occurred more than 30 minutes flying
time from the nearest suitable airport, or
Forward galley (typical aircraft)
Source: ATSB
if there had been a delay prior to landing, numerous flight-critical
systems would have subsequently become unavailable’, it says.
These would have included autopilot, communications and instrument
systems, and would have reduced the crew to ‘flying by hand with
only visual and tactile references, a standby airspeed indicator, a
standby magnetic compass and a standby altimeter with degraded
reliability to guide them’ the ATSB said, noting that the risk of spatial
disorientation and resulting loss of control in such conditions would
have been ‘particularly acute’. ‘Personal mobile telephones’ would
have been the only source of air-to- ground communications.
The ATSB found that the incident was indeed related to the puddle of
water that the cabin service manager had reported. How it came to
jeopardise 346 passengers and 19 crew is a fascinating and cautionary
tale for anyone who works on, or flies, an aircraft of any size.
The investigation found that water had probably overflowed from
the aircraft’s forward galley floor drain as a result of a blockage in
that drain, possibly due to ice forming in or near the drain mast. The
water had flowed forwards, through a gap beneath the forward galley
bulkhead and a gap in the decompression panel, into the space where
the bus controllers were housed.
Signs of long-term water damage were found on three of the generator
control units. To reach these units the water had probably entered the
gutter of a dripshield and leaked through the joints at each end, and
possibly through cracks around the dripshield’s fasteners.
The ATSB report listed other similar
incidents. A US Boeing 747 had flight control
anomalies following a water leak in the cabin;
an Irish Airbus A300 had multiple system
failures on a night instrument approach
after a leak caused by a frozen water tank;
there were several cases of electrical fires in
DC-9s caused by leaks from the forward toilet;
and a Boeing 737 began ‘uncommanded roll
and yaw oscillations,’ after water got into its
avionics compartments.
In the three years following the Bangkok
incident there were four other minor incidents
involving water leaks in Qantas or ex-Qantas
aircraft.
It had dripped onto a brace on the top of the equipment rack, and
travelled along that brace and into the electrical equipment, through
ventilation holes in the top of the equipment.
Qantas inspected its 747 fleet and found 18
damaged dripshields in 30 aircraft. There
were also 12 damaged drain line heaters.
Those heaters only had to be inspected at
every 12-yearly D check, which in the case of
the aircraft involved would have been about
four years before the incident.
The ATSB concluded that the location of a decompression panel
(installed by Qantas) and absence of cabin floor sealing above where
the generator control units were situated ‘increased the risk of liquid
ingress into the aircraft’s electrical systems’.
The sealing around the wet galley area was not adequate but was
unlikely to have contributed to the problem, it found.
The decompression panel comprised a hinged panel that was held
shut with a spring, and had a perimeter gap of about 3mm.
At least one of the seeds for this frightening incident had been planted
years earlier, the ATSB found. Boeing 747-400s originally came from
the factory with two outlets for the main and upper deck drains (these
drained waste water overboard from galleys, galley drains, lavatory
wash basins, and drinking fountains).
But that system left water marks on the outside of the fuselage, so
Qantas replaced it with a longer drain mast that had only one outlet.
The two drain lines were combined with a rubber Y-section into the
single outlet. This engineering change had been applied to all the
Qantas 747 fleet by 1992.
The airline installed a water barrier at the
rear of the forward galley bulkhead on all
its 747-400s. It also applied more sealant to
protect the decompression panel.
Boeing issued service letters and service
bulletins, and the Federal Aviation
Administration (FAA) issued airworthiness
directives
requiring
inspection
and
improvement of the dripshields on various
747 versions.
But this is not just a story about water: it’s
also about systems and how they interact.
The abstract concepts of redundancy, parallel
systems and avoidance of single point failures
are important.
continued on page 41
33
AIRWORTHINESS
Forward galley area with bulkhead and floor panels removed (typical aircraft)
Source: ATSB
PULL-OUT SECTION
It is easy to be critical in hindsight, but it is
also obvious that the change required one
drain outlet to do the work of two drain
outlets. A tiny bit of parallel separation
or redundancy had been taken out of the
747’s design.
SELECTED SERVICE DIFFICULTY REPORTS
1 August 2011 –
15 September 2011
Note: Similar occurrence figures not included
in this edition
AIRCRAFT ABOVE 5700kg
Airbus A320232 Main landing gear door
actuator failed. SDR 510013537
RH main landing gear door actuator slow
in operation.
P/No: 114122012. TSN: 9,244 hours/5,191 cycles.
PULL-OUT SECTION
Airbus A330202 Cargo smoke detection
activated. SDR 510013332
Forward cargo smoke detection warning.
Cargo fire bottles fired. Investigation continuing.
FSA NOV-DEC 2011
34
Airbus A330202 Passenger service unit oxygen
mask door failed test. SDR 510013379
Passenger Service Unit (PSU) 37DEFG oxygen
mask door would not open due to one latch failing
to unlock. Investigation continuing.
P/No: 65C1505B0020005.
Airbus A330203 Landing gear brakes suspected
faulty. SDR 510013497
Brakes would not release after park brake disengaged.
Investigation could find no definitive cause for the
defect but the brake steering control unit (BSCU) was
changed as a precaution.
Airbus A330303 Crew oxygen system low
pressure. SDR 510013507
Crew oxygen system lost pressure. Nil indication
of pressure loss. Investigation continuing.
Airbus A380842 Passenger service unit oxygen
manifold cracked/leaking. SDR 510013371
Numerous passenger service unit (PSU) oxygen
manifolds cracked. See attachments for a list of
affected items. Investigation continuing.
BAC 146200A APU firewall cracked.
SDR 510013563
APU firewall cracked in two places.
Found during inspection iaw AD/BAE146/053.
Investigation continuing.
Boeing 717200 Aircraft lightning strike –
elevator trailing edge. SDR 510013325
Aircraft struck by lightning. Investigation found
RH elevator trailing edge rivet burnt.
Boeing 717200 Aircraft over-speed.
SDR 510013483
Aircraft suffered an over-speed during descent
in turbulence. Over-speed inspection could find
no damage.
Boeing 717200 APU carbon seal leaking –
cabin smell. SDR 510013310
Slight smell in cabin. Caused by APU carbon
seal leaking.
Boeing 737376 Horizontal stabiliser
jackscrew unserviceable. SDR 510013290
Horizontal stabiliser jackscrew assembly
unserviceable. Jackscrew was unable to be correctly
lubricated with discoloured grease from the lower
seal but nil grease from the upper seal or grease vent.
P/No: 654997025.
TSN: 59,593 hours. TSO: 2,965 hours.
Boeing 737476 Co-pilot’s sliding window
outer pane cracked/arcing. SDR 510013300
First Officer's No. 2 sliding window outer pane cracked
and arcing.P/No: 5717623096.
TSN: 503,860 hours. TSO: 503,860 hours.
Boeing 737476 Elevator tab assemblies
incorrectly fitted. SDR 510013375
Suspect incorrect installation of LH and RH elevator
tab assemblies. Found during inspection iaw EI 7370055-0025 R04. Investigation continuing.
Boeing 737476 Fuselage ram air fairing blowout
panel missing. SDR 510013416
LH ram air fairing blowout panel missing/separated.
P/No: 6548675165.
Boeing 7374L7 Galley oven fumes.
SDR 510013471
Fumes from rear galley. Investigation found
No. 2 oven C304 faulty. P/No: GENM2585015.
TSN: 48,359 hours. TSO: 12,246 hours.
Boeing 737838 Aileron and rudder trim
module faulty. SDR 510013498
Nil LH rudder trim. Investigation found a faulty aileron
and rudder trim module. Investigation continuing.
P/No: 697370313.
Boeing 737838 Electric hydraulic pump
unserviceable. SDR 510013339
System 'B’ electric hydraulic pump internal short
circuit. Investigation found AC motor phases shorting
to ground case drain. P/No: 887477.
TSN: 24,453 hours. TSO: 24,453 hours.
Boeing 737838 Elevator mast and output torque
tube crank arm bearings worn. SDR 510013356
LH and RH elevator mast and output torque tube crank
arm bearings worn beyond limits. Both bearings
had approximately 7.62mm (0.3in) free-play. Limit
5.33mm (0.210in).
Boeing 737838 Spoiler actuator faulty.
SDR 510013297
No. 4 spoiler actuator faulty causing spoiler to vibrate
during operation. P/No: 251A12403.
TSN: 31,746 hours. TSO: 31,746 hours.
Boeing 7378FE Landing gear door partially open.
SDR 510013437
Landing gear failed to retract following take-off.
Investigation found the landing gear manual extension
access door not fully closed and access door
microswitch out of adjustment.
Boeing 737BBJ Cockpit windows cracked.
SDR 510013417
Both cockpit No. 2 windows cracked in vinyl interlayer.
No. 4 and No. 5 windows have discolouration
and cracking of urethane interlayer. Found during
inspection iaw IE-056-0101R01.
Boeing 747 Wing trailing edge flap skin
delaminated. SDR 510013571 (photo below)
LH outboard trailing edge flap skin delaminated
and separated in flight. Area of skin loss
approximately 2.43m by 0.6m (8ft by 2ft).
Aircraft overseas registered.
Boeing 737838 Engine bleed air cabin fumes.
SDR 510013433
Fumes in cabin. Investigation found compressor
wash had been carried out overnight.
Boeing 737838 Engine bleed air pre-cooler
control valve faulty. SDR 510013560
RH engine bleed air system pre-cooler control valve
faulty. P/No: 32895625.
TSN: 14,898 hours. TSO: 7,318 hours.
Boeing 737838 Engine spar valve motor failed.
SDR 510013528
No. 2 engine spar valve electric motor failed.
P/No: MA30A1001. TSN: 312 hours. TSO: 312 hours.
Boeing 737838 Horizontal stabiliser jackscrew
metal contamination. SDR 510013295
Horizontal stabiliser jackscrew grease contaminated
with metal particles. Initial investigation found plating
coming off. Found during investigation iaw EI N37-27130R2. Investigation continuing.
Boeing 737838 Nose landing gear bushing faulty.
SDR 510013499
Nose landing gear release roller failed to return to the
retract position. Release roller/cam roller connecting
shaft seized. Following rectification the roller still
failed to return to the correct position. Suspect
bushings still providing too much friction. Investigation
continuing. Found during nose landing gear manual
extension test iaw EW-2474931.
Boeing 737838 Nose landing gear release
assembly failed. SDR 510013450
Nose landing gear manual extension release assembly
failed. Investigation found bolt was tight but had
wound out approximately 6.3mm (0.25in) and was
contacting stop on the cam unit, preventing operation.
P/No: 273A45102.
Boeing 737838 Nose landing gear release roller
failed to reset during test. SDR 510013572
Nose landing gear release roller failed to reset
following manual extension test iaw EA: MM04719.
Boeing 737838 Nose landing gear spring broken.
SDR 510013510
Nose landing gear manual extension spring broken.
Boeing 737838 Passenger seat belt signs wires
burnt. SDR 510013418
Passenger seat belt signs located at seats 12 to 15 DEF
unable to be switched off due to burnt and unsecured
earth lugs for wires W6242-2431B-18, W62422432B-18 and W62422433b-18.
Boeing 74748E Engine uncommanded thrust
increase. SDR 510013419
No. 1 engine uncommanded thrust increase to
106.4 per cent. Investigation continuing.
Boeing 747438 Flight deck emergency door
handle incorrectly assembled. SDR 510013466
Flight deck emergency exit door handle fitted with
incorrect orientation. Handle was indicating ‘open’
when ‘locked’ and vice versa.
Boeing 747438 Main landing gear tyre separated.
SDR 510013381
Body landing gear No7 main wheel tyre tread
separated. Damage to fuselage and hydraulic lines.
Landing gear tilt problem. Investigation found a
steel rod approximately 279mm long by 19.05mm in
diameter (11in by 0.75in) amongst the tyre debris on
the runway. The rod was identified as being an item
of tooling used during tyre to wheel mounting by the
wheel maintenance service provider.
Boeing 747438 Override/jettison pump discharge
pipe flange cracked. SDR 510013316
Uncommanded fuel transfer. Investigation found
the 3M tank forward override/jettison pump
discharge line mating flange circumference cracked
at the discharge check valve interface. Crack length
approximately 95.25mm (3.75in).
Boeing 767336 Auto-flight system controller
failed. SDR 510013541
Nil autopilot function. Mode selection panel (MSP)
frozen. Investigation continuing. P/No: 6224717003.
Boeing 767336 Engine frame support fairing
missing. SDR 510013473
RH engine LH ‘A’ frame support fairing partially
missing. Missing piece approximately 127mm (5in).
Boeing 767336 Main landing gear failed
to retract. SDR 510013451
RH main landing gear failed to retract.
Investigation continuing.
Boeing 767338ER Hydraulic motor generator
controller incorrectly wired. SDR 510013552
LH and RH hydraulic motor generator (HMG) controller
connectors transposed. Investigation continuing.
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.
Lear 35A Main landing gear up limit switch out
of adjustment. SDR 510013353
LH main landing gear up limit switch (S5) out
of adjustment. P/No: 1CH16.
Bombardier DHC8102 Cargo hold smoke detector
unserviceable. SDR 510013562
No. 2 cargo hold smoke detector unserviceable.
Investigation found the detector had a slight amount
of charring/burning on the external casing. A slight
carbon deposit was also found on the protective grill.
Investigation continuing. P/No: 47359714.
Bombardier DHC8202 Auxiliary fuel tank
pump faulty. SDR 510013491
No. 1 auxiliary fuel tank pump faulty and failing
to transfer fuel. Investigation continuing.
Bombardier DHC8102 Engine oil cooler cracked
and leaking. SDR 510013348 (photo below)
LH engine oil cooler cracked longitudinally
through weld. Loss of engine oil. P/No: 28E997.
Bombardier DHC8402 Wing attachment bolt
barrel nut unserviceable. SDR 510013327
RH forward inboard wing attachment bolt barrel
nut loose. See attachment for investigation details.
TSN: 5,573 hours/6,355 cycles.
Bombardier DHC8202 Starter-generator suspect
faulty. SDR 510013555
No. 2 engine starter-generator suspect faulty.
Investigation continuing. P/No: 23088008.
Bombardier DHC8315 Flight control system
faulty. SDR 510013405
Flight control system faulty. Stick pusher and stall
warning system failure.
Bombardier DHC8315 Nose landing gear actuator
hose leaking. SDR 510013501
Nose landing gear drag strut actuator flexible
hose leaking.
P/No: DSC252B40124. TSN: 9,006 cycles.
Bombardier DHC8402 Ice and rain protection
systems heater damaged. SDR 510013320
(photo below)
Engine intake adapter heater damaged due to
overheating during operation. Evidence of possible
flame generation. Investigation continuing.
TSN: 5,796 hours. TSO: 6,640 hours.
Embraer ERJ190100 APU oil system metal
contamination. SDR 510013559
APU oil system chip detector metal contamination.
Metal particles found to be larger than 0.15mm
(0.006in). Investigation continuing.
TSN: 1,849 hours/2,424 cycles.
Embraer ERJ190100 Flap lower outboard control
rod distorted. SDR 510013557
Flap over-speed. Investigation found LH and RH
flap lower outboard control rods P/No: 92387-901 and
P/No: 92385-901 bent. P/No: 92387901.
Embraer ERJ190100 Integrated pitot/static/AOA
sensor unserviceable. SDR 510013269
Integrated pitot/static/AOA sensor 3 unserviceable.
P/No: 2015G2H2H8A. TSN: 2 hours/1 cycle.
Embraer ERJ190100 Passenger service
unit oxygen latch release tool broken.
SDR 510013282
Passenger service unit (PSU) oxygen latch release
tool probe broken. Manual deployment of oxygen
masks affected.
35
AIRCRAFT BELOW 5700kg
Beech 200 Dual bus feeder diodes failed.
SDR 510013545
No. 2 dual bus feeder diodes failed at anode
connection. See attachment for investigation
and rectification details. P/No: 70HF10.
Beech 200 Electrical bus feeder diode faulty.
SDR 510013479
No. 2 electrical bus feeder diode CR2 breaking down
internally due to loose anode. P/No: 70HF10.
Beech 200 Flap drive shaft sheared.
SDR 510013481
RH inboard flap driveshaft sheared at gearbox end.
Suspect caused by incorrect rigging.
P/No: 1013800002.
TSN: 226 hours/228cycles/4 months.
Beech 200 Wing leading edge skin cracked.
SDR 510013366 (photo below)
RH wing upper leading edge skin cracked in area
adjacent to upper forward wing attachment fitting
inboard screw. Crack located between Stn 124.616
and Stn 147.735. P/No: 00011010916.
TSN: 12,706 hours/15,241 landings.
Fokker F27MK50 Propeller blade de-ice boot
burnt. SDR 510013464
LH propeller blade de-ice boot burnt.
Fokker F28MK0100 Autopilot system failed.
SDR 510013472
No. 2 autopilot system failed. Investigation continuing.
Bombardier DHC8402 Main landing gear wheel
tie bolt loose. SDR 510013322 (photo following)
RH main landing gear inboard wheel tie
bolt loose. Found during inspection iaw MA-3247-Q400. TSN: 7,799 hours/9,015 cycles.
TSO: 132 hours/138 cycles.
Fokker F28MK0100 Co-pilot’s windshield
cracked. SDR 510013573
First officer's windshield cracked.
Pilot's vision obscured.
TSN: 2,976 hours/2,369 cycles. TSO: 2,976
hours/2,369 cycles.
Fokker F28MK0100 Elevator cable tension
regulator bearing excessive play.
SDR 510013273
Elevator cable tension regulator LH bearing bellcrank
excessive play. P/No: D78179707.
Beech 200 Wing spar attachment fitting barrel
nut incorrectly assembled. SDR 510013502
RH outer wing main spar upper attachment fitting
barrel nut bore damaged (gouged). Investigation found
damage caused by an incorrectly assembled barrel nut.
Found during inspection iaw SIRM 57-17-02 and AD/
Beech200/38. P/No: 80691CF1216.
TSN: 12,895 hours/15,464 landings.
AIRWORTHINESS
Bombardier DHC8202 Hydraulic line damaged.
SDR 510013477
Flexible hydraulic line split and leaking. Loss of
hydraulic fluid. Line is located in area of No. 1 engine
cowling. P/No: DSC252D40134180.
Embraer ERJ170100 Engine PRSOV
unserviceable. SDR 510013368
LH engine HP and LP pressure regulating and
shutoff valves (PRSOV) have suspect excessive
blow-by causing erratic engine ITT indications.
Investigation continuing. P/No: 10012461X2OFF.
TSN: 10,378 hours/8,116 cycles.
Saab SF340B Nose landing gear strut retraction
pin fractured. SDR 510013544
(photo below)
Nose landing gear strut retraction pin fractured and
partially withdrawn from cylinder. Suspect caused by
hydrogen embrittlement due to corrosion.
P/No: AIR127298.
TSN: 25,173 cycles. TSO: 11,991 cycles.
PULL-OUT SECTION
Embraer EMB120 APU bleed air duct corroded.
SDR 510013398 (photo below)
APU bleed air duct had severe corrosion and numerous
holes under insulation layers. P/No: 12044169001.
Saab SF340B Landing gear control CB wire worn
and damaged. SDR 510013278
Landing gear control circuit breaker power wire
GA401-1601 and adjacent wires chafed and arcing
causing damage to cockpit frame FSTN 200.
Wiring installed as part of SB 32-120 in June 2000.
Investigation continuing. P/No: GA4011601.
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.
Gulfstream 500S Pilot’s rudder pedal bolt loose.
SDR 510013546
Pilot's LH rudder pedal attachment bolt loose.
Beech 58 Aircraft emergency window partially
open in flight. SDR 510013456
RH emergency exit window opened during flight.
Inspection found no fault with the latching system
and it is suspected that a passenger might have been
leaning on the window.
Jabiru 170CLSA Landing gear brakes locked up.
SDR 510013533
Brakes locked during landing. Pilot decided to go
around but a wheel contacted a fence at the end
of the runway and the aircraft crashed. Aircraft
registered with Recreational Aviation Australia.
TSN: 49 hours.
Britten Norman BN2A20 Landing gear brake
caliper failed. SDR 510013440
RH brake caliper failed at attachment pins.
P/No: 3023D.
PULL-OUT SECTION
Britten Norman BN2A21 Engine air intake
duct unserviceable. SDR 510013547
Engine air intake duct unserviceable.
Found during inspection iaw AD/BN2/057.
P/No: TU195MM660MMCC.
Cessna 172N Cigarette lighter resistor burnt.
SDR 510013478
Cigarette lighter voltage dropping resistor shortcircuited and burnt.
P/No: S20415016. TSN: 13,367 hours.
Cessna 172S Aileron cable worn. SDR 510013514
RH aileron cable in roof area worn.
P/No: MC0510105362. TSN: 1,338 hours.
Cessna 182E Pilot’s control column bearing
failed. SDR 510013387 (photo below)
Pilot's control column support bearing failed.
Investigation found needles unserviceable.
P/No: 0760633-1. TSN: 12,434 hours.
Cessna 402C Elevator control system suspect
faulty. SDR 510013540
Elevator control system suspect faulty. Investigation
checked for FOD and cable tensions with no adverse
results found. System checked serviceable.
Cessna 402C Main landing gear torque link
washer missing. SDR 510013313
RH main landing gear torque link and bush separated.
Initial investigation found there were no washers fitted
under the split pinned bolt. Investigation continuing.
P/No: 50450182.
Jabiru J230DL Engine throttle cable seized.
SDR 510013531
Engine throttle seized in open position during engine
start. Aircraft moved of its own accord and sustained
a damaged wing and broken propeller as it crashed
into the door of a nearby hangar. Investigation found
a protruding grub screw on the throttle rod prevented
the throttle from being retarded. Aircraft registered
with Recreational Aviation Australia.
TSN: 165 hours.
Pilatus PC12 Flap attachment arm cracked.
SDR 510013377 (photo below)
LH flap inboard attachment arm assembly cracked
in area of upper fork end. P/No: 5275212153.
TSN: 10,244 hours/13,381cycles/131 months.
Cessna M337B Wing fuel line corroded.
SDR 510013358
LH wing fuel line located between spar union and
sump tank had pinhole corrosion. P/No: 140010625.
36
FSA NOV-DEC 2011
Cessna 402C Elevator actuator chain sprocket
jammed - FOD. SDR 510013527
Loss of full elevator-up movement. Investigation found
a small ‘rivet nail’ approximately 5mm by 1.5mm
(0.19in by 0.05in) jammed in the actuator chain
sprocket. Full movement restored when FOD removed.
P/No: PA495A2.
Diamond DA40 Electric pedal adjuster broken.
SDR 510013470
LH electric pedal adjuster failed. Investigation
found the rubber drive belt had missing teeth.
Driven gear also had two missing teeth.
P/No: D6027233021. TSN: 104 hours.
Cessna 208 Landing gear brake line end fitting
on float failed. SDR 510013281
LH brake line end fitting on float failed. Loss of
hydraulic pressure.
Cessna 208B Trailing edge flap tube nuts loose.
SDR 510013489
RH trailing edge flap interconnect tube nuts loose.
During rigging check, the drive rods from the
bellcranks to the flaps were also found to be binding.
TSN: 341 hours.
Cessna 210M Horizontal stabiliser attachment
fitting cracked. SDR 510013566 (photo below)
Horizontal stabiliser attachment fitting cracked.
P/No: 12324001.
Diamond DA42 Elevator lever cracked.
SDR 510013280
Elevator lever cracked from forward elevator
attachment point extending approximately 25mm (1in)
forward and approximately 40mm (1.57in) rearward of
the hole. Crack extended approximately 75 per cent of
the depth of the lever.
P/No: D42735301. TSN: 1,569 hours.
Gippsland GA8 Pitot tube heater connector
faulty. SDR 510013574 (photo below)
Pitot tube heater connector burnt/damaged.
P/No: GA8341001.
Pilatus PC12 Flight control warning unit failed.
SDR 510013409
Flap control warning unit failed. P/No: 9787320017.
TSN: 7,265 hours/5,754 landings.
Piper PA28140 Wing spar cap corroded.
SDR 510013426
LH wing inboard spar lower spar cap had exfoliation
corrosion for approximately100mm (4in).
P/No: 620706. TSN: 6,705 hours.
Piper PA31350 Flap flexible drive shaft
failed test. SDR 510013400
RH trailing edge flap flexible driveshaft failed
measurement test iaw AD/PA31/101-3.
P/No: 00486597. TSO: 500 hours.
Piper PA31350 Wing aileron spar corroded.
SDR 510013411
RH aileron spar corroded underneath balance weight.
Found during inspection iaw AD/PA31/118-2.
TSO: 500 hours.
Piper PA31 Main landing gear torque link broken.
SDR 510013482
LH main landing gear torque link broken. P/No: 40256.
Piper PA34200T Hydraulic power pack
unserviceable. SDR 510013272
Hydraulic power pack unserviceable. P/No: HYC5005.
Gulfstream 114 Elevator spar cracked.
SDR 510013538 (photo below)
RH elevator spar cracked in area located just below
the outboard hinge. P/No: 4421110. TSN: 2,500 hours.
Cessna 210N Horizontal stabiliser rear bracket
broken. SDR 510013553 (photo following)
LH horizontal stabiliser rear bracket P/No: 1232400-1
broken. During investigation, the RH rear bracket
P/No: 1232400-2 was also found to be cracked.
P/No: 12324001.
Swearingen SA227AC Engine oil tube cracked
and leaking. SDR 510013365
RH engine oil line between propeller governor and
negative torque signal (NTS) cross assembly cracked
adjacent to flared end. Loss of engine oil pressure.
P/No: 31080811.
Swearingen SA227DC Electrical system
wire broken. SDR 510013485
Wire from terminal 6 on terminal strip TS 311
broken resulting in loss of nose wheel steering
and failure of landing gear to extend.
P/No: 200007AB22. TSN: 13,934 hours/17,129
cycles/17,129 landings/220 months. TSO: 13,934
hours/17,129 cycles/17,129 landings/220 months.
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.
Swearingen SA227DC Landing gear failed
to extend. SDR 510013487
Landing gear failed to extend on selection.
Approximately 20 seconds later it extended normally.
TSN: 25,622 hours/26,361 cycles/26,361 landings/209
months. TSO: 25,622 hours/26,361 cycles/26,361
landings/209 months.
Eurocopter BK117C2 Main transmission oil
filter metal contamination. SDR 510013404
Main transmission chip light illuminated. Investigation
found excessive metal contamination in oil filter.
P/No: B632K1001051. TSN: 814 hours/2,524
cycles/2,524 landings/33 months. TSO: 814
hours/2,524 cycles/2,526 landings/33 months.
ROTORCRAFT
Robinson R22BETA Main rotor blade debonded.
SDR 510013506
Main rotor blade skin debonded on lower surface in
the area of the blade tip. Debond area approximately
20mm by 10mm (0.78in by 0.39in). Found during tap
testing iaw AD/R22/54 Amdt1 and FAA 2011-12-10.
Investigation continuing. TSN: 318 hours.
Agusta Westland AW139 Main rotor servo
actuator pressure switch unserviceable.
SDR 510013407
No. 1 main rotor servo actuator No. 2 system
pressure switch unserviceable.
P/No: 7079785. TSN: 174 hours/339 cycles/339
landings/12 months. TSO: 174 hours/339 cycles/339
landings/12 months.
Agusta Westland AW139 Tail rotor blade
cracked. SDR 510013462
Tail rotor blade cracked in area of composite
attachment. Found during inspection iaw EASA AD
2011-0156-E.
P/No: 3G6410A00131. TSN: 138 hours.
Bell 412 Pilot’s collective stick throttle linkage
over lubricated. SDR 510013403
Pilot's collective stick throttle linkage system
over-lubricated, causing eventual sticking of
gears/linkages.
P/No: 212001164129. TSN: 58 hours.
Robinson R44 Main rotor drive transmission
failed. SDR 510013422
Transmission failed during flight resulting in loss
of drive between engine and main rotor. During
autorotation, the aircraft landed heavily, causing
the skids to spread and the main rotor to strike the
tail boom. Initial investigation of the transmission
chip detector found a significant amount of metal.
Investigation continuing.
P/No: C0065. TSN: 2,037 hours. TSO: 2,037 hours.
Robinson R44 Main rotor drive systems
split pin missing. SDR 510013423
Main rotor gearbox input coupling yoke assembly nut
cotter pin missing. P/No: MS24665210.
Robinson R44 Tail rotor blade skin cracked.
SDR 510013539 (photo below)
Tail rotor blade skin cracked.
P/No: C0292. TSN: 1,168 hours.
Jabiru 2200 Engine through bolt broken.
SDR 510013529
Engine through bolt broken. Bolt located between
No. 3 and No. 4 cylinders. Aircraft registered
with RAA. TSN: 130 hours.
Jabiru 2200J Engine through bolt undersize.
SDR 510013436
Replacement engine through bolts approximately
0.254mm (0.010in) undersize. P/No: 4291044.
Lycoming AEIO360B2F Engine FCU servo
contaminated. SDR 510013267
Fuel control unit (FCU) servo contaminated with
green sludge from fuel dye.
P/No: 252429111. TSO: 417 hours.
Lycoming IGSO480A1E6 Engine crankcase
cracked and leaking. SDR 510013520
LH engine LH crankcase half cracked in area between
No. 4 and No. 6 cylinders adjacent to No. 6 cylinder
forward upper cylinder base stud.
P/No: 75355. TSO: 76 hours/38 cycles/38 landings/
4 months.
Lycoming IO540AC1A5 Engine fuel injector line
cracked. SDR 510013567
Engine forward LH upper fuel injector line cracked.
TSN: 648 hours.
Eurocopter AS332L Intermediate gearbox fairing
cracked. SDR 510013367
Intermediate gearbox fairing cracked.
Found during inspection iaw AD 2011-0129-E.
P/No: 332A2403030601.
Lycoming IO540K1B5 Engine exhaust tailpipe
separated. SDR 510013434
RH engine tailpipe separated and fell into water.
P/No: NB53235. TSN: 1 hour. TSO: 1 hour.
Eurocopter AS365N Main rotor servo controller
diode failed. SDR 510013394
Main rotor servo control connection box P/No: 800646
faulty. Investigation found a failed
diode in circuit board P/No: 802170 and moisture
ingress from the cracked connection box.
P/No: 800646. TSN: 1,530 hours. TSO: 1,530 hours.
PISTON ENGINES
Eurocopter AS365N Tail rotor hub to blade
torsion bar cracked. SDR 510013543
(photo below)
Tail rotor hub to blade torsion bar had one laminate
cracked and separated.
P/No: 365A33352700. TSN: 6,586 hours.
Continental IO360D Engine injector line worn.
SDR 510013357
Rear engine injector lines Nos. 1, 2, 4 and 5 P/No:
630657, P/No: 630658, P/No: 630650 and P/No:
630651 worn beyond limits. Found during inspection
iaw AD/Con/60. P/No: 630657.
Continental IO520L Engine magneto seized.
SDR 510013430
RH magneto seized. Metal contamination of engine.
P/No: 103493505. TSO: 166 hours.
Jabiru 2200 Engine cylinder inlet valve
separated. SDR 510013535 (photo following)
No. 2 cylinder inlet valve separated from valve
stem causing internal damage. Valve stem seized
in valve guide. Aircraft registered with RAA.
P/No: 2200. TSN: 764 hours.
Lycoming IO580B1A Engine oil filter metal
contamination. SDR 510013372
Following fitting of new engine, during test flight
the oil pressure was seen to bleed off. Suspected
contamination of oil pressure relief valve. Investigation
found some non-ferrous metal flakes in the oil filter.
Lycoming LTIO540J2BD Engine cylinder exhaust
valve damaged. SDR 510013565
RH engine No. 6 cylinder exhaust valve cracked
and broken with several pieces missing.
P/No: LW16740. TSN: 1,066 hours.
Lycoming O235H2C Engine spark plugs/magneto
suspect faulty. SDR 510013522
Engine vibration and misfiring soon after take-off.
Unable to duplicate fault on the ground. Magneto
replaced but tested serviceable. Spark plugs
suspected to be breaking down at high RPM.
All plugs bench tested as serviceable but were
replaced as a precaution.
P/No: REM37BY.
Lycoming O360A1A Engine big end bearing
delaminated. SDR 510013314
No. 4 connecting rod big end bearing delaminating.
Metal in oil filter. TSN: 368 hours.
37
AIRWORTHINESS
Bell 212 Elevator horn support bracket cracked.
SDR 510013323
LH elevator horn support bracket cracked for
approximately 50mm (1.96in). Investigation found
the support frame P/No: 205-030-820-015 had been
replaced with the original six aft rivets being replaced
with Cherry Max rivets P/No: CR3243-5 that had not
pulled up correctly, allowing the bracket to move.
P/No: 205030889015. TSN: 2,652 hours.
Robinson R44 Main rotor drive systems drive
belt partially separated. SDR 510013265
Engine to transmission drive belt beginning to separate
at join. P/No: A1903. TSN: 102 hours.
Jabiru 2200 Engine failed. SDR 510013526
Engine failed. Engine made a loud noise followed
by power loss. Aircraft badly damaged during
emergency landing. Aircraft registered with RAA.
P/No: 2200. TSN: 1,600 hours.
PULL-OUT SECTION
Agusta Westland AW139 Pilot’s cyclic
stick flight trim switch unserviceable.
SDR 510013461
Pilot's cyclic stick flight trim release switch
unserviceable. P/No: 92801880101.
TSN: 1,206 hours/3,123 landings/32 months.
Robinson R22BETA Tail rotor drive flex plate
unserviceable. SDR 510013324
Tail rotor drive shaft flex plate washers debonded
causing fretting to flex plate and driveshaft.
P/No: A9473. TSN: 1,163 hours.
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.
Lycoming TIO540AH1A Engine fuel pump drive
failed. SDR 510013561
Engine-driven fuel pump drive failed. Investigation
found pump not seized. TSN: 126 hours.
Lycoming TIO540AH1A Engine fuel pump drive
shaft failed. SDR 510013386
Engine-driven fuel pump drive failed. Investigation
found pump not seized.
P/No: 200F5002. TSN: 1,106 hours.
PULL-OUT SECTION
Lycoming TIO540J2BD Engine cylinder piston
rings broken. SDR 510013564
LH engine No. 3 cylinder piston rings broken.
Cylinder replaced due to scoring in bore.
P/No: ST203P010. TSN: 1,033 hours.
FSA NOV-DEC 2011
38
Lycoming TIO540J2BD Engine cylinder valve
lifter seized. SDR 510013513
LH engine No. 1 and No. 3 cylinders had zero
compression. No. 1 cylinder valve lifter seized.
Further investigation found internal damage.
Investigation continuing.
TURBINE ENGINES
Allison 250C20B Pc safety valve unserviceable.
SDR 510013359
Pc safety valve located between compressor
scroll and Pc filter failed, allowing the rear of the valve
to become dislodged. P/No: 250954106.
Garrett TPE33110N Engine oil scavenge
pump failed. SDR 510013525
RH engine low oil pressure. Initial investigation
suspected oil scavenge pump failure.
Investigation continuing.
TSN: 12,938 hours/10,008 cycles. TSO: 4,992
hours/3,730 cycles.
GE CFM567B Engine oil scavenge line leaking.
SDR 510013317
No. 1 engine aft sump scavenge line leaking.
Correct tooling for repair not available on site
so engine changed. P/No: CFM567B26.
TSN: 18,502 hours. TSO: 18,502 hours.
GE CT79B Engine chip indication. SDR 510013277
LH engine chip detector light came on at first
intermittently and then continuously. Nil other
indications. Investigation found chip detector
contaminated with M50 bearing material.
Engine removed for investigation and report.
GE GE90115B Engine bleed valve door rod
end bearing broken. SDR 510013283
LH engine bleed valve door rod end bearing broken.
TSN: 11,705 hours/1,076 cycles.
Lycoming ALF502R5 Engine failed.
SDR 510013449
No. 4 engine failed. Engine suffered vibrations and
fire warning with TGT rising to 1080 degrees. Engine
shut down and fire bottle fired. Inspection of the
exhaust found signs of molten debris and metallic
sand- like debris as well as damage to the exit blades.
Investigation continuing.
PWA PT6A41 Engine hot section damaged.
SDR 510013568
Engine hot section damaged. Found during
borescope inspection.
PWA PT6A114A Engine over-speed.
SDR 510013275
Trend monitoring indicated engine Np over-speed
beyond manufacturer's limits. Engine removed
for investigation and report.
Garrett TPE33114GR Engine bearing oil
line worn. SDR 510013363
LH engine rear bearing oil supply line worn and leaking.
P/No: 31041793.
PWA PW206C Engine bearing oil tube fractured.
SDR 510013354
LH engine No. 5 bearing oil pressure tube fractured
and leaking.
P/No: 312110901. TSN: 1,597 hours.
GE CF680C2 Engine fuel pump and filter metal
contamination. SDR 510013286
RH engine fuel pump and filter contaminated with
metal. Investigation found a chipped edge on the pump
internal carbon seal.
Rolls Royce RB211524G Engine fuel nozzle
feed tube cracked. SDR 510013301
No. 2 engine No. 18 fuel nozzle feed tube cracked and
leaking. Investigation continuing. P/No: FK29501.
GE CFM567B Cockpit fumes due to engine
compressor wash. SDR 510013556
Strong oily fumes on flight deck. Investigation found
No. 1 engine had a compressor wash before flight.
Rolls Royce TAY65015 Engine low oil pressure.
SDR 510013467
No. 1 engine low oil pressure. Investigation found
high speed gearbox oil return tube chip detector
and combined oil-drain tube chip detector had
collected metal particles. Metal particles also
found on both sides of the oil pressure filter and
in the high-speed gearbox strainer. Suspect caused
by failed high-speed gearbox starter idler gear.
Investigation continuing.
PROPELLERS
Hamilton Standard 14SF23 Propeller autofeather
system failed to engage. SDR 510013515
Autofeather system failed to arm. Investigation found
no definitive cause for the defect.
Hartzell HCC2YR1 Propeller blade damaged.
SDR 510013518
Propeller blade tip separated approximately 12.7mm
(0.5in) from tip. Aircraft overseas registered.
P/No: HCC2YR1
COMPONENTS
EAM KSE-35HC2LB Lifejacket battery
deteriorated. SDR 510013548
Lifejacket battery deteriorated and showing signs
of stress. Lifejacket manufactured by Eastern
Aero Marine.
P/No: WABH18. TSN: 22 months.
Regent RSS-301 Lifejacket battery deteriorated.
SDR 510012945 (photo below)
Very strong chemical smell evident when lifejacket
was opened to use as a training aid. Investigation
found its battery had become unstable. Another
three lifejackets checked - same problem found.
Date of manufacture: Aug 2008. Expiry date:
Nov 2018. P/No: WABH18. TSN: 40 months.
Rolls Royce TAY65015 Engine fluctuates.
SDR 510013279
LH engine parameters fluctuated during takeoff. Investigation found parameters fell within
maintenance manual limits. Weather conditions
at the time were rain and 20kt crosswinds, with
a temperature of 19 degrees.
TO REPORT URGENT DEFECTS
CALL: 131
757
FAX:
02 6217 1920
or contact your local CASA Airworthiness Inspector [freepost]
Service Difficulty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601
Online: www.casa.gov.au/airworth/sdr/
AIRWORTHINESS DIRECTIVES
15 - 28 July 2011
Equipment
Rotorcraft
Fire protection equipment
Agusta AB139 and AW139 series helicopters
AD/FPE/6 Amdt 7 - fire extinguishant systems.
CANCELLED
2011-0140 Communications - primus epic harnesses
solder splices. Inspection/replacement
Eurocopter EC 225 series helicopters
2011-0136R1 Equipment and furnishings - VHF antenna
for emergency flotation gear protection. Installation
Oxygen systems
2011-14-08 B/E Aerospace oxygen masks - oxygen
mask assemblies - broken in-line flow indicators
Bombardier (Canadair) CL-600 (Challenger)
series aeroplanes
CF-2011-28 Oxygen supply system - deformation
of pressure regulator on the oxygen cylinder and
regulator assembly
Bombardier (Boeing Canada/De Havilland)
DHC-8 series aeroplanes
CF-2011-29 Hydraulic accumulators - screw cap/end
cap failure
Below 5700kg
29 July - 11 August 2011
Embraer EMB-110 (Bandeirante)
series aeroplanes
Agusta A109 series helicopters
Lycoming and Superior Air Parts
piston engines
2011-0031 CN Tail rotor drive shafts. Inspection,
replacement. CANCELLED
2011-15-10 This AD has been moved to the ‘fuel supply
and metering equipment’ series
2011-0150 Elevator upper skin. Inspection,
replacement, repair
Turbine engines
AD/EMB-110/8 Amdt 6 - Flap actuators
Above 5700kg
AD/A320/151 Keel beam side panels. CANCELLED
AD/A320/154 Amdt 1 - Integrated drive generator
connector. CANCELLED
2011-0134 Fuselage - Keel beam side panels.
Inspection
Eurocopter BK 117 series helicopters
2011-0148 Optional equipment - external rescue hoist
system. Deactivation, modification
2011-0149 Electrical power - generator control unit.
Identification, replacement
2011-0137 (Correction) Equipment/furnishings Passenger compartment class divider/gas spring
damper. Inspection, replacement
Eurocopter SA 360 and SA 365 (Dauphin)
series helicopters
Airbus Industrie A330 series aeroplanes
2011-0145 Time limits and maintenance checks - tail
gearbox (TGB) oil level and magnetic chip detector.
Inspection. Tail rotor - pitch control rod bearing.
Inspection, replacement
AD/A330/86 Amdt 3 - MLG bogie beam. CANCELLED
2011-0138 Navigation - Pitot probe quick-disconnect
union. Torque check
2011-0139 Hydraulic power - high pressure manifold
check valves. Inspection
2011-0144 Tail rotor hub
Below 5700kg
Airparts (NZ) Ltd. FU 24 series aeroplanes
DCA/FU24/180 - Hopper lid
Beechcraft 300 series aeroplanes
AD/CESSNA 206/47 Amdt 3 - Rear door
emergency exit
2011-15-05 FAA-approved flight manual.
Correction to take-off speeds and field length
Boeing 737 series aeroplanes
AD/B737/201 Amdt 3 - rudder control system
Cessna 206 series aeroplanes
Cessna 337 series aeroplanes
2011-15-11 Installed Flint Aero Inc. wing tip tanks
STC SA5090NM
De Havilland DHC-1 (Chipmunk)
series aeroplanes
Turbomeca turbine engines - Makila series
2011-0147 Engine indicating - N2 sensor harness.
Replacement
Equipment
Fuel supply and metering equipment
2011-15-10 AVStar Fuel Systems (AFS) fuel servo
diaphragm (previously published in Lycoming and
Superior piston engine series)
12 - 25 August 2011
Rotorcraft
2011-0154 Rotor flight controls - collective pitch lever
restraining tab. Inspection, adjustment
Kawasaki BK 117 series helicopters
TCD-7916-2011 Cockpit and cabin door outside handles
Below 5700kg
De Havilland DHC-1 (Chipmunk)
series aeroplanes
AD/DHC-1/41 Amdt 1 Fuselage rear bulkhead.
Inspection and modification
AD/DHC-1/40 Canopy lock. Modification
AD/DHC-1/43 Amdt 1 Engine primer pipe and fuel
tank selector guide. Modifications, inspections and
replacements
2011-14-11 No.2 and No.3 engine pylon wire bundle
routing. Inspection
AD/DHC-1/41 Fuselage rear bulkhead. Inspection
and modification
AD/DHC-1/44 Amdt 1 Mandatory modifications,
inspections and replacements
2011-15-03 Sleeving and wire bundles of the fore and
aft boost pumps
AD/DHC-1/42 Tailplane to fuselage pickup.
Modification
Fairchild (Swearingen) SA226 and SA227
series aeroplanes
AD/DHC-1/43 Engine primer pipe and fuel tank selector
guide. Modification, inspection and replacement
2011-17-07 Primary flight control cables
Boeing 747 series aeroplanes
AD/B747/171 Amdt 5 - Outboard main fuel tank boost
pump wiring. CANCELLED
Bombardier (Canadair) CL-600 (Challenger)
series aeroplanes
CF-2010-35R1 Hydraulic accumulators - screw cap/
end cap failure
AD/DHC-1/44 Mandatory modifications, inspections
and replacements
CF-2011-23 Potential damage to third crewman
oxygen system
Embraer EMB-110 (Bandeirante)
series aeroplanes
CF-2011-25, 26 and 27 Air-driven generator failure
to power essential buses
AD/EMB-110/13 Amdt 7 - rudder upper hinge support
Bombardier (Boeing Canada/De Havilland)
DHC-8 series aeroplanes
Pacific Aerospace Corporation Cresco
series aeroplanes
DCA/CRESCO/17 Hopper lid
Above 5700kg
Airbus Industrie A319, A320 and A321
series aeroplanes
2010-0165-CN Oxygen system - passenger oxygen
masks. Identification, modification, replacement
Airbus Industrie A380 series aeroplanes
2011-0058R2 (Correction) Pneumatic - pylon bleed
duct. Inspection, replacement
2011-0151 Wings - wing flap track 1 Aft Z-link (second
load path) lower attachments. Inspection, repair
CF-2011-20 Power lever assembly - fouling of UK
CAA flight idle gate
Above 5700kg
CF-2011-21 Fuel system - chafing of high pressure
fuel line
AD/B737/164 Amdt 2 Elevator tab repair
Avions de Transport Regional ATR 42
series aeroplanes
AD/B737/201 Amdt 4 Rudder control system
AD/ATR 42/26 Amdt 1 Cockpit forward side windows
Boeing 747 and 767 series aeroplanes
Bombardier (Canadair) CL-600 (Challenger)
series aeroplanes
CF-2011-22 Electrical - AC generator rotor band failure
CF-2011-24 Wing to fuselage attachment joints - barrel
nut cracking
Boeing 737 series aeroplanes
2011-16-02 Boeing 747/767 equipped with CF6-80C2
or CF6-80A series engines - ice and rain protection
limitations section of the Boeing 747/767 AFM
2011-16-06 Main equipment centre drip shields
39
Eurocopter SA 360 and SA 365 (Dauphin)
series helicopters
CF-2011-30 Cracking on the forward face of the rear
pressure bulkhead web
CF-2011-33 Engine support beam - cracking on the
upper and lower web
AIRWORTHINESS
2011-0141 Landing gear - main landing gear (MLG)
bogie beam. Inspection, repair, modification
Piston engines
PULL-OUT SECTION
Airbus Industrie A319, A320 and A321
series aeroplanes
Rotorcraft
AIRWORTHINESS DIRECTIVES ... CONT.
Bombardier (Boeing Canada/De Havilland)
DHC-8 series aeroplanes
Eurocopter AS 355 (Twin Ecureuil)
series helicopters
2011-0155 Time limits and maintenance checks fuel airworthiness limitations
CF-2011-34 Ice protection system - failure of timer
and monitor unit
2011-0164 Rotors flight control - tail rotor control
stop screws
2011-0160 Equipment/furnishings - escape slide raft.
Modification, replacement
CF-2011-31 Incorrect heat treatment of
pushrod assembly
Eurocopter BK 117 series helicopters
2011-0167 Oxygen - chemical emergency oxygen
containers. Identification, modification
CF-2011-32 Rudder control - excessive wear on
brake pedal bellcrank
Fokker F100 (F28 Mk 100) series aeroplanes
AD/F100/30 Amdt 1 - flight warning computer.
Replacement
Piston engines
PULL-OUT SECTION
Thielert piston engines
FSA NOV-DEC 2011
40
2011-0152-E Engine - clutch assembly.
Identification, replacement
Turbine engines
AlliedSignal (Garrett/AiResearch) turbine
engines - TPE 331 series
2011-0162 Electrical power - generator relay after
junction box. Modification
2011-0168 Lights - instrument lighting display
brightness for flight in night vision goggle (NVG)
mode. Modification
Eurocopter EC 135 series helicopters
2011-0168 Lights - instrument lighting display
brightness for flight in night vision goggle (NVG)
mode. Modification
2011-0172 Fire protection - fire extinguishing system
injection tubes. Replacement
Eurocopter SA 360 and SA 365 (Dauphin)
series helicopters
2011-18-51 PMA main shaft bearings
AD/DAUPHIN/80 Rotor flight controls - collective
pitch lever restraining tab. CANCELLED
General Electric turbine engines - CF6 series
Below 5700kg
2011-18-01 Fluorescent penetrant inspection (FPI)
of Stage 3 low-pressure turbine (LPT)
General Electric turbine engines CF34 series
2011-18-02 Replacement of fan rotor blade retainers
and fan rotor spinner support
26 August - 8 September 2011
Cessna 150, F150, 152 & F152
series aeroplanes
Airbus Industrie A330 series aeroplanes
2011-0170 Landing gear - main landing gear (MLG)
wheel axle - reduced life limit following repair
2011-0171 Fuselage - frame (FR) 40 Fuselage skin
panel junction. Inspection
Boeing 737 series aeroplanes
AD/B737/52 Amdt 3 - Corrosion prevention and
control program (CPCP)
AD/B737/152 Amdt 1 - Centre fuel tank - limitations
AD/B737/198 Amdt 2 - Centre tank fuel pumps
AD/B737/202 Amdt 2 - Centre fuel tank limitations
Cessna 210 series aeroplanes
2011-18-03 Centre tank fuel boost pump automatic
shut-off
AD/CESSNA 210/36 Windshield and windows fatigue life limitation. CANCELLED
TECNAM P2006T Series aeroplanes
2011-0156-e Tail rotor blades. Inspection,
replacement [reduced life limitation]
Above 5700kg
2011-0164 Rotors flight control - tail rotor control
stop screws
2011-0166 - Doors - Main Wing Landing Gear Door
(MWLGD) Rear Hinge Fitting
AD/B737/347 Amdt 1 - Centre wing tank auto
shut-off wiring
Agusta AB139 and AW139 series helicopters
Eurocopter AS 350 (Ecureuil)
series helicopters
2011-0165 - Wings - Movable Flap Track Fairing
Number 4 (MFTF #4) Pivot Brackets
2009-10-09 R2 Rudder limit stops
2011-0153-e Landing gear - emergency
accumulator for landing gear (LG) extension.
Inspection, modification, replacement
Rotorcraft
Airbus Industrie A380 Series aeroplanes
Airbus Industrie A319, A320 and A321
series aeroplanes
AD/A320/195 Amdt 1 Fuel tank safety - fuel
airworthiness limitations. CANCELLED
Fokker F100 (F28 Mk 100) series aeroplanes
2011-0157 Time limits/maintenance checks maintenance requirements. Implementation
2011-0159 Landing gear - main landing gear
(MLG) piston
2011-0158 Fuel - fuel-balance transfer system.
Deactivation
AD/F100/97 Amdt 1 - State of design airworthiness
directives
2010-0112R1 Oxygen system - passenger oxygen
masks. Identification, modification
continued from page 33
subchapter, must be designed to ensure that
they perform their intended functions under
any foreseeable operating condition,’ it says.
Forward drain mast and ribbon heater (prior to the drain mast modification)
Source: ATSB
Redundancy means different systems that do the same job, parallel
systems means similar jobs being done by separate systems, and a
single point failure is any part, from a nut to a software program,
that could cause an entire system to fail, or indeed put the aircraft in
danger. You need to keep these concepts in your mental toolkit, and
apply them to every job.
They are as important as calipers or sockets in a physical toolkit.
As aircraft, particularly GA aircraft, age, LAMEs find themselves
having to redesign or re-create peripheral systems that were never
intended to last for as long as they have. This is a minefield for
engineers. Peripheral systems are not as well documented in design
or manufacture as major systems, but they can significantly affect the
safety of the aircraft, as QF2 shows.
In other words, ‘This goes with this goes with that,’ is more than the
slogan of a fashion chain. It’s a phrase any engineer modifying a
system should keep in mind as they contemplate making a change,
however slight. Always consider the worst possible scenario.
Part 25.1309 of the FAA design regulations for transport aircraft
such as the Boeing 747 is a stringent requirement. ‘The equipment,
systems, and installations whose functioning is required by this
The question then arises as to whether these
errors can be classed as anyone’s fault. That
is a legal question, not an engineering one.
Cold hard 1309 analysis before the job is
always better than a hot flush of doubt or
guilt after it.
This is meant as a cautionary tale, not a fingerpointing exercise. As has been said before,
pilots close the hangar doors at the end of the
day. Engineering decisions, or a chain of both
related and unrelated maintenance actions by
various maintenance engineers can sow the
seeds of destruction which, when developed,
bear deadly fruit.
The moral of the story is: There are
some things anyone involved in aircraft
maintenance or operation should forget.
One of them is the saying: ‘Look after
the big things and the small things will
look after themselves.’ It’s just not true
in aviation. If you work in design or
maintenance your job is to sweat over the
finest details. Welcome to the hangar.
41
AIRWORTHINESS
The second point of this story is the really
frightening one for engineers. Changes that
breach safety can go unnoticed for years.
You may have created a single point of
failure – a pathogen in the system, to use
James Reason’s phrase – but everything can
work fine for years, as long as one critical
component functions. In this case it was the
drain line ribbon heater – when it gave up the
ghost the water backed up and found the next
best way out – through the decompression
panel into the main equipment bay.
PULL-OUT SECTION
That’s a high standard – the FAA didn’t
say any reasonably foreseeable operating
condition. The FAA wants design engineers
to think hard about the very worst thing that
could happen before they initiate a design
or make a change. In other words you must
follow the discipline of 1309 analysis.
Hawker Pacific First
CASR PART 145
PULL-OUT SECTION
Hawker Pacific’s aviation maintenance and
repair organisation, Hawker Pacific Airline
Support Services, is the first in Australia
to be approved under Part 145 of the new
maintenance regulations.
FSA NOV-DEC 2011
42
Director of Aviation Safety, John McCormick,
presented the Part 145 approval certificate to
Hawker Pacific in Cairns, where they carry
out maintenance of Bombardier DH-8s and
Embraer 120s. He praised the organisation
for the amount of work they had done to gain
the approval, which followed CASA’s careful
review of all their documentation, and on-site
inspections.
But Jim Pilkington, Hawker Pacific’s Vice
President Quality and Systems, was quick
to explain that this ‘first’ should not put the
company on a pedestal. ‘We’re not perfect’,
he says, rather describing this ongoing
process as being ‘on a journey.’
Under Part 145, maintenance organisations
must have a safety management system
(SMS) and provide human factors (HF)
training for aircraft engineers. Emphasising
the ongoing process, Pilkington outlined
the company’s journey. ‘It began in 2000
at Safeskies, where I was part of a panel
presenting on harmonisation and the
push for common regulations worldwide.
Every regulator,’ he argues, ‘even though
there may be minor variations, wants their
maintenance organisations to carry out the
work in good facilities; with competent,
trained and authorised personnel, using the
correct, calibrated tooling, in accordance
with approved and current data.’
Hawker Pacific voluntarily embarked on a process of standardising
and integrating all their documentation, via an intranet, ideal for
their geographically dispersed sites. In the early stages much of this
documentation was in Excel spreadsheets, but the employment in
2004 of an aviation safety manager, and the purchase and setting
up of a database, Pilkington says, ‘was a major factor in integrating
processes. We put everything in the database – it all goes in there for
trending. Holding over 40 certificates across 20 aviation authorities is
a complexity which requires simplicity.’
The next step in their journey was to undergo European Aviation Safety
Agency (EASA) Part 145 certification, and following a substantial audit
of their Queensland and Singapore operations by the French Direction
Générale de l'Aviation Civile (DGAC) Hawker Pacific became EASA
Part 145 accredited in 2005.
Hawker Pacific’s SMS continues to evolve. ‘It’s a five-year timeline with
different stages, and we’re not at the fifth stage yet, where the whole
process becomes generative,’ says Pilkington. Initial human factors
training was conducted using an external consultant, but he adds,
‘then we brought it in house, because it has to be tailored to what you
do. And there’s such a wealth of (HF) reference material out there –
especially the UK CAA’s (Civil Aviation Authority’s) CAP 716 on human
factors: “the bible”.’
CASA expects that by June 2013, almost 200 maintenance organisations
will transition to operating under the new Part 145.
The transition of RPT operators and maintainers of RPT operators will
take place from 27 June 2011 to 26 June 2013. If you wish to transition
your organisation, or for more information on transitioning to Parts
42 and 145 of the new maintenance regulations, please contact the
Permission Application Centre (PAC) at regservices@casa.gov.au or
by calling 131 757.
Hallmarks of the ‘generative safety culture’
Information is actively sought
Messengers are trained
Responsibilities are shared
Bridging is rewarded
Failure causes enquiry
New ideas are welcomed
Safety Management and Safety Culture: The Long, Hard and Winding Road
Prof. Patrick Hudson
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43
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Phone: (02) 6584 0484
Email: info@johnstonaviation.com.au
Web: www.johnstonaviation.com.au
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continued from page 29
CONCLUSIONS
Two interesting conclusions arose from the study:
1. There is a much higher risk of a fatal
accident resulting from manoeuvring to
avoid wind turbines than by colliding with
them (particularly in conditions below
VMC); and
2. Collision with unmarked obstacles, either
WMTs or power lines, during the conduct
of aerial agricultural activities is the
highest risk to aviation safety arising from
wind farms.
FSA NOV-DEC 2011
44
Due to this higher risk from manoeuvring to
avoid turbines, it makes sense not to locate
wind turbines in areas of concentrated low level
air traffic such as published VFR routes. The
issue of stress of weather leading to flight below
500ft (and potentially into conflict with wind
turbines) should also be considered. Where air
traffic is likely to be funnelled through a gap or
area of lower terrain due to low cloud, it should
be remembered that wind turbines are usually
located on the tops of hills and therefore clear of
low-level escape routes.
Because terrain and aircraft operations vary, it also makes sense
that an independent aviation hazard/risk assessment is carried
out of all proposed wind farms. This assessment should include
feedback from the local flying community regarding the extent of
low-level flying operations, and consideration of any limitations
to VFR tracking in adverse weather.
The potential for collision with unmarked hazards, which
occurred in four of the eight cases, is clearly more problematic.
It is likely that such a catastrophic collision will occur again,
possibly in Australia.
This study therefore recommends that:
All WMTs and their supporting guy wires should be marked to
enhance visibility;
An online searchable database of WMTs’ location and other
applicable details, preferably referenced to their geographic
location, should be developed for the use of low-level
aircraft operators; and
Power lines located in close proximity to known areas of lowlevel aircraft operations should be marked appropriately.
Some countries have already acted on this trend. Following
the most recent WMT accident, the USA’s Federal Aviation
Administration (FAA) formally recommended the painting of
WMT as advised in Advisory Circular 74-7460-1 Obstruction
Marking and Lighting. It also recommended the use of highvisibility sleeves and spherical markers on the supporting guy
wires. Following the FAA’s initial response, Transport Canada
released Advisory Circular 600-001 Marking of Meteorological
Towers. This recommends the painting of towers and installing
orange marker balls at the top of the guy wires.
In the United Kingdom, recently-published Aeronautical
Information Circular P021/2011 Tall Structures Promulgation
and Visual Conspicuity recommends the marking and/or lighting
of WMTs to safeguard aerodromes, although the marking and/
or lighting of WMTs not in the vicinity of aerodromes is not
addressed.
Australia has established a working group, of which CASA is
a member – the National Air Space Safeguarding Advisory
Group (NASAG) – bringing together all interested parties (state
and territory planning and transport departments, Airservices
Australia, the Department of Defence and the Australian Local
Government Association [ALGA]), and chaired by the Department
of Infrastructure and Transport (DoIT).
This is looking at, among other airspace issues, wind turbines
and wind monitoring towers. CASA has no regulatory powers
regarding wind turbines or wind monitoring towers beyond a
30km radius of an aerodrome. In the absence of such regulations,
CASA is trying to provide guidance to inform proponents on how
best to act diligently. It is envisaged that NASAG’s role will be
to provide guidance to state planning authorities, given that
building regulations relating to obstructions and hazards are a
state planning function.
The Aerial Agricultural Association of Australia, whom NASAG is
liaising with, considers wind-monitoring towers to be a significant
hazard to aerial agriculture operations. It recommends marking
of wind monitoring towers and power lines, and proposes a
mandatory national system of communicating the position of all
wind monitoring towers and including the details on a national
database accessible to low-level pilots.
Defence also conducts low-level flying, and since a near-miss
incident involving an FA/18 and a wind monitoring mast in South
Australia a couple of years ago, has a similar concern.
Wind and aviation industry coordination on obstacle data has a
way to go, but the RAAF is collecting data, and if a wind farm
goes ahead, developers should advise the location, extent and
height of the wind farm to:
As a result of the research study, Aviation Projects is
sponsoring a Masters project aimed at quantifying
the risk in Australia of an aircraft colliding with an
unmarked wind monitoring tower, and developing
a prototype online database and search tool linked
to a geographic reference.
SUMMARY
Action has commenced elsewhere to address
the risks posed by wind monitoring towers,
and Australia is developing a coherent strategy.
Australia has a proud aerial agricultural
activity and aviation safety record. Positive,
coordinated and ongoing action is necessary to
avoid compromising aviation safety as the wind
industry’s dynamic progress accelerates.
USEFUL LINKS
Bureau d’Enquêtes et d’Analyses pour la
sécurité de l’aviation civile (BEA) (France)
The reporting of tall structures requirement for RAAF AIS
(CASA AC 139-08) is generally for approved structures, namely
‘as constructed’ information provided once built. However, for
wind farms Defence has assessed, Defence also requests that
developers provide wind turbine design information, not only ‘as
constructed’, but also before construction to RAAF AIS.
Civil Aviation Authority (CAA) (UK), Aeronautical
Information Circular: P 021/2011: Tall Structures
Promulgation and Visual Conspicuity
Defence also requests the chance to assess all wind farm
proposals, including wind-monitoring masts, at the investigation
stage. Email details to the directorate of external land planning at
lpsi.directorate@defence.gov.au
Transport Canada, Advisory Circular
600-001 Marking of Meteorological Towers
Federal Aviation Administration (FAA) (USA),
Marking Meteorological Evaluation Towers
FAA, Advisory Circular 70-7460-1 Obstruction
Marking and Lighting
Transport Canada, Debrief: MET Towers:
A collision can happen and it has happened.
Australian Department of Infrastructure
and Transport
www.infrastructure.gov.au/aviation/
environmental/safeguarding.aspx
Australia has established a working group ... the National Air Space Safeguarding
Advisory Group (NASAG), looking at, among other airspace issues, wind turbines and
wind monitoring towers.
45
WIND FARMS
Aeronautical Data Officer
RAAF AIS (VBM-M2)
Victoria Barracks
St Kilda Road Southbank VIC 3006, or
Email ais.charting@defence.gov.au
Before construction proceeds, developers must
also provide CASA with details of the wind farm
so that CASA can issue a NOTAM advising airspace
users of the construction. When construction is
complete, developers must also notify CASA of
the location and blade tip height in AMSL (m) of
each turbine, so that a permanent NOTAM can
be issued.
Programmed to deceive
Name withheld by request
FSA NOV-DEC 2011
46
The amazing technology that
directs you to wherever you
want to go will just as happily
direct you to where you don’t
want to go, as this commercial
pilot discovered
The flight started as a routine transit from
Coober Pedy to Port Augusta in South Australia.
I had planned via the standard IFR route to the
west of Woomera’s restricted areas that had
been active earlier that day, and all was well
with the aircraft as I departed Coober Pedy and
called Melbourne Centre with my estimates.
I was advised that Woomera had ceased
operations for the day, and a direct route would
be available to Port Augusta, (YPAG). This I
happily accepted, as it would save about 10
minutes of flight time and fuel. Since I was flying
a pressurised turboprop, the saving was worth
considering. The clearance was issued, I made
the track adjustment, climbed to 27,000 feet and
settled in for the one-hour trip.
My aircraft was equipped with an IFR GPS, as
well as a separate moving map with its own GPS
database. Although independent systems, they
talk to each other, and the moving map displays
fixes and tracks from the other unit.
All was well, and the weather was perfect up there, as it generally is above
the clouds. We were in bright sunshine, with everything going to plan and
an early return home expected because my passengers had finished their
business early. I even noticed that the GPS was indicating we were making
very good time and had a good tailwind. I couldn’t have been happier.
Top of descent arrived, and I called Melbourne Centre to obtain clearance
and traffic, and started down. By this time, the cloud below had built to a solid
layer with the tops around 18,000ft, but this was not unusual for the time of
year, and I had ascertained that Port Augusta was clear, expecting a simple
visual arrival. As we popped out of cloud at 12,000ft, I was surprised to note
that the terrain looked unlike what I had been expecting for this stage of the
flight. We were over a large salt lake that should have been some miles behind
us, and I couldn’t see the top of Spencer Gulf, as I would have expected to
from that height. I suddenly realised that I wasn’t where I thought I was, and I
was getting there at nearly 300kt!
I stopped the descent and started a troubleshooting cycle to see where I was,
and why I was there. Part of my cycle included zooming in on the moving
map to see what it had to say. In fact it told me a couple of things. Firstly, it
showed the aircraft to be over the southern end of Lake Torrens but, more
interestingly, it showed a waypoint for the Port Augusta airport to be there
as well!
That of course couldn’t be accurate, so the error had to be related to the GPS
programming. I didn’t have time to delve any further into the GPS at that stage,
because we were still some distance from Port Augusta, and I busied myself
with setting up the ADF to track to the aid, making certain I could stay visual
for the remainder of the trip, and amending my ETA with Melbourne Centre.
The rest of the trip went without incident, but after landing I had to get to the
bottom of my GPS error.
47
With this particular GPS unit, there were a large number of waypoints preprogrammed into the certified database, and updated from time to time by the
manufacturer. There were also user waypoints that could be set by the pilot.
These took the form of Lat/Long, Brg/Dist, or Rad/Dist, depending on how you
wanted to set it up. It became evident that at some point previously a pilot had
entered a waypoint into the GPS, some 56nm to the north of Port Augusta,
based on the Leigh Creek VOR, and called it YPAG! This was significant for
a couple of reasons. Firstly, you should never use a name that indicates
the airport position in this manner as it can be confused with the standard
identifiers. Secondly, when this is done, it overrides the GPS programming,
and the unit then displays this new ‘user waypoint’ whenever the airport is
selected on the GPS. Lastly, if you set up a user waypoint in a GPS, and you
are not the only pilot of that aircraft, you should have some kind of naming
convention, or you should delete the waypoint after you’ve used it so as not
to confuse anybody else, or have numerous similar waypoints in the system
with different names.
Now that I had discovered the error in the GPS, I had to work out why it had
caused my difficulty. That was actually the easy part.
As I departed Coober Pedy and obtained a direct clearance, I had inadvertently
set the GPS up to use the airport waypoint instead of the NDB.
This, I can only rationalise, was because I so often go to airfields that have
no aid, and therefore are entered into the GPS with the four letter identifier.
In reality, it shouldn’t have made any significant
difference, as the Port Augusta NDB is located
very close to the airport, but the procedure
is valid and in place nevertheless. Secondly,
while I normally would do a confidence check
by comparing my flight plan distances, bearings
and times with the GPS data I had just entered,
this check wasn’t available once I had selected
‘direct to’. My flight plan was of little assistance
to confirm the new data. In fact, only the distance
to go would have been obviously different
anyway, as the new waypoint was almost on the
direct track. Combined with the strong tailwind,
the shorter distance gave me a very good time
interval, but instead of simply accepting it, I
should have investigated further. I should also
have zoomed in on the moving map much earlier,
when I would have been able to see the variation
in waypoint locations.
It was a timely reminder that when relying on
the GPS for remote area navigation, you should
also check with other sources of information and
not simply accept that the GPS data is correct.
Normally it will be, but every now and then, it will
surprise you. I’m just thankful that this occurred
in daytime and good weather. I can live with the
embarrassment, but the situation could have
been very different at night or in bad weather!
CLOSE CALLS
Firstly, I checked the accuracy of the current GPS position against the ADF
indication and the airport chart. All looked as it should. This was getting
frustrating. Then, I entered the airport reference on the GPS, and was
shocked to find that it was 56nm away! I had found the error , but why was
the GPS telling me this? It turned out to be a very simple solution.
He who rides
a Tiger
Name and address withheld by request
FSA NOV-DEC 2011
48
Too much confidence and not
enough anticipation gave a
normally thoughtful young pilot
a memorable fright
At the beginning of 2005 I was fortunate enough to land
my first flying job at a small aerodrome located near
Melbourne. I was 22 at the time and, like most young
pilots fresh out of university, was willing to take a job
anywhere, anytime and for next to nothing.
Fortunately this was a full-time position which paid more
than the award for a junior grade 3 flight instructor, in
addition to being located not too far from my home town.
My duties involved both flight and ground instruction
through the flying school’s AOC, and private and charter
flights through the charter company’s AOC to and from
such places as Flinders Island, northern Tasmania and
Phillip Island.
One of the best parts of the job was the unusually high
number of aircraft types available to use for both flight
training and charters. My favourite was the DH82 Tiger
Moth. At the time we had two well-maintained Tigers, as
well as an AgCat.
It wasn’t too long before I had my chance to fly the Tiger
and I took it with open arms. Before I knew it I had over
100 hours on the aircraft, which may not sound like much
but when you consider that the average joy flight lasted
for approximately 20 minutes, the number of take-offs
and landings quickly added up.
This story relates to one particular flight I undertook
in the Tiger on Anzac Day 2005. I was to fly in the left
echelon position behind an experienced agricultural pilot
in the AgCat and to the left of the second (slightly betterperforming) Tiger, being flown by a very experienced and
well-respected colleague who had previously trained me
on the Tiger. I had a small amount of formation experience
after having been signed off a few weeks earlier and felt
comfortable about participating in the display with the
time I had on the Tiger.
We had briefly discussed the flight over coffee during the
morning and I had been given permission to carry one of
my students in the front seat.
As we lined up I took a moment to reflect on how lucky I
had been to snag this as my first job, as I knew I’d be able
to look back on flights like this and smile.
The time had arrived to begin our take-off roll and
perform our display over the nearby town of Cranbourne
before the arrival of the Roulettes who would do a low
pass en route to the Shrine of Remembrance. As the lead
aircraft began to roll I carefully introduced power to roll
in unison with the Tiger to my right.
As we approached our rotate speed I began to get that
feeling in the bottom of my gut that something wasn’t
right, and in a matter of seconds I found out why.
Before lining up I had noted the direction of the wind,
which was to be at our two o’clock position during the
take-off roll. I put it down to my lack of experience in
formation flying that I failed to realise that being in the
position I was, the wash from the two-metre wide propeller
on the AgCat was going to drift across directly in front of
All I could do was try not to over
control the aircraft by resisting the
temptation to pull further back on
the stick, and hopefully ride it out.
the track I was to be taking. This, combined with the
fact that I was trying to keep up with the slightly betterperforming Tiger Moth on my right by rotating slightly
earlier than I usually would was going to mean I’d have
to fight to keep control of the aircraft during flight at such
low IAS.
Sure enough, as we slowly became airborne I could feel
the aircraft yawing and rolling toward the left, bringing
us dangerously close to the aircraft parked alongside
the runway. I had full right stick and a small amount
of right rudder depressed in an effort to regain control.
The problem was that the Tiger Moth was only designed
with ailerons on the lower wings, greatly reducing the rollrate available.
After having caught up with the guys afterwards, I realised
they had no idea how close I had come to disaster, and
I’m sure what I remember about the event has somewhat
been slightly overdramatised. However, I have learnt
many valuable lessons from it.
If I were to offer any advice to anyone, it would be to those
fellow aviators who are currently trekking, and those who
are yet to trek, down the all-too-familiar path of gaining
their hours as quickly as possible in order to reach their
goal of perhaps flying a commercial jet aircraft.
I’m sure that there will be a stage during the early years
of your career at which you become so confident in your
ability to fly an aircraft that you will forget, if only
momentarily, how quickly things can become
pear-shaped.
I hate to say it but I was probably too confident in my
somewhat, limited flying ability and I almost paid the
ultimate price. Please be careful not to make the same
mistake, whether you’re conducting circuits in a Cessna
172 as a Grade 1 META Instructor or ferrying an empty
Piper Chieftain from Bathurst Island to Darwin.
Good luck and happy flying.
49
CLOSE CALLS
All I could do was try not to over control the aircraft
by resisting the temptation to pull further back on the
stick, and hopefully ride it out. And ride it out we did!
Within seconds, but after what felt like an eternity, the
aircraft began to climb and roll to the right. I regained my
composure and, shortly after, joined up with the group.
I’m glad to say the remainder of the flight was a complete
success and I enjoyed myself immensely.
Sure enough, this will be the time at which you will find
yourself in trouble and hoping against hope you can rectify
the situation ASAP. I was fortunate to have resisted the
temptation to over-control the aircraft in an attempt to
correct the situation.
Almost pressing the grapes!
Bruce Campbell
A nighttime simulated engine failure could easily
have added human claret to the wine.
FSA NOV-DEC 2011
50
Looking back on my time as an instructor I can
honestly say that I enjoyed (almost) every minute of
the flying. There were times, though, when I had to
think quickly, work hard, and use all my resources
to keep our aircraft flying, or get it back on the
ground safely.
These experiences included a real engine failure
(single engine) on take-off from Archerfield,
when the Restricted PPL on an under-supervision
navex just froze and kept the aircraft in the climb
attitude. I had been apparently uninterested in his
procedures, but was observing him closely in the
side-window reflection of the C172. I literally shoved
the nose down and selected full flap – we were
at about 100ft AGL. We touched down on the far
piano keys and managed to skid to a stop just short
of the boundary fence. Problem? Stuck valves and
bent pushrods.
Another incident was another real engine failure
in the circuit. I just happened to be on a close
downwind leg and landed safely across the field
in the general grass area, carefully avoiding cones
and gable markers. This time it was a cracked
cylinder, about 2cm from the crankcase. The crack
extended around three quarters of the cylinder and
a couple more seconds of operation would have
seen a catastrophic separation.
Yet another was an aileron control malfunction
(on a Beech 23) in the training area at around
4000ft. The aircraft suddenly rolled to the right and
it required nearly full continuous opposite aileron
application to keep the wings level. We landed
safely. Cause? Half the aileron’s self-centring device
was broken, hence full inadvertent roll the other
way. There were many other very tense moments
with aircraft problems, but none of them related to
maintenance issues.
But the real humdinger of a close call occurred
just before I gained my CPL. I was undertaking fulltime training at Cessnock in the late 1960s, having
completed my PPL and some part-time training
towards CPL at Archerfield. My licence was already
endorsed with CSU/retractable, so most of my
training at Cessnock was on a Piper Arrow PA28-R.
Cessnock aerodrome was then, and still is, in the
middle of the Hunter Valley wine district. Grapes
were grown immediately to the east of the field
boundary, between there and the main road.
I’ve had to consult my first logbook to clarify
dates and flying sequences/hours immediately
preceding this close call. The sequence, I believe,
is important, and probably has some relevance to
what happened.
The CPL training, including NVMC, was proceeding
apace daily, and nightly, and was in the final
polishing stages. On the previous day I had flown
for 7 hours 40 minutes, comprising separate day
and NVMC navs and night aids work on a third
sortie, all pilot-in-command - under supervision
(PICUS). It was approaching first light when I finally
hit the sack exhausted! Someone woke me later,
and when I asked the time, I was told it was early
afternoon. Another two training sessions in the
Arrow followed, the second late in the afternoon,
followed by a night navaids period, (again PICUS),
around Maitland some hours after tea. We returned
to base on an outbound track from Maitland.
Overhead Cessnock at 1710ft on AQNH (Cessnock
elevation 211ft), we commenced a right turn to
let down for a right-hand circuit on runway 36,
(required because of high terrain to the west). The
oil-pot flares for runway lighting were still OK, only
one or two out but not the threshold ones, and radio
calls had confirmed no other traffic in the circuit.
Only the altimeter, used correctly,
can provide the ultimate
guide to glide path relative
to a fixed illuminated point,
such as threshold lights.
51
All was normal. Checks were completed quickly,
and I concentrated on the approach, using the
flare path as my primary visual cue. I remember
cutting the corner on base leg, and starting to
turn final quite close in. I can still see it in my mind’s
eye. The wings were not quite level and we weren’t
lined up when the engine gave a tremendous roar,
spluttered and caught. My right hand had firewalled
the throttle too quickly, and the instructor’s left
hand was on top of mine! In the split second this
happened, we had both woken up to the altimeter
reading 360ft.
Not lined up, and no, we didn’t have 360ft to
descend. We had both been briefly lulled into
thinking that ground level was at zero feet. Somehow
we clawed our way back to an acceptable climb
speed, to the right of and parallel to the runway,
(over the grapes, remember, and I recall seeing the
needle under 300ft), cleaned up the aircraft, and
completed a normal circuit and landing. I don’t
recall much of a de-brief from the instructor, if at all.
We had almost made bloodied wine.
From memory, I don’t think the incident was
mentioned to the CFI, and was just passed off
as one of those things that happen in training.
I certainly didn’t want to cop any flack at this stage.
I was too busy to reflect on it in the coming days; my
flight test was scheduled for later in the week.
It wasn’t until some ten years later, when, as a senior
instructor and CFI teaching NVMC, that I thought
seriously about this particular close call. Daytime
simulated forced landings are a breeze – you can
see the ground and judge height. But at night it’s
oh so different. You have considerably fewer visual
cues, even in the circuit with a flarepath to guide
you. Only the altimeter, used correctly, can provide
the ultimate guide to glide path relative to a fixed
illuminated point, such as threshold lights.
Undoubtedly, the primary contributing factor in this
incident was misreading the altimeter relative to
circuit heights (being lined up by 500 AGL on final),
but over-work and tiredness contributed immensely
to this predicament. I have been ever mindful to
remind my students constantly about these points.
It has taken me nearly thirty years to decide to put
pen to paper about this incident, after reading
about many others in the ‘crash comic’. There were
many incidents, of varying degrees of danger,
during my time in the left and right-hand seats, but
none ever quite like this.
CLOSE CALLS
Right at this point, my instructor, only a few years my
senior, (he was probably just shy of thirty), pulled
the power and nonchalantly said, ‘Engine failure’.
I immediately requested that he hold the gear override lever up to stop the warning horn continuously
blaring, and I commenced a glide approach,
electing not to select gear down until I was sure of
making it.
;OL(\Z[YHSPHU
Themes from
ATSB
investigations—
what’s worrying
us
I recently had the pleasure
of meeting with my regional
aviation colleagues at the RAAA convention in
Coolum, Queensland.
The convention was a great opportunity to catch up
52 with the many dedicated people involved in regional
FSA NOV-DEC 2011
aviation. I was also reminded of the vital role regional
aviation plays in keeping Australia safely connected.
During the convention, I discussed the major findings
emerging from our investigations into aviation
accidents and incidents. Some of these findings are
starting to form patterns or themes of aviation safety
concerns and are worth sharing with you here. They
include:
s Issues with some elements of pilot training—
particularly for regular passenger transport pilots
in the handling of standard but rarely performed
procedures.
s Problems with stabilised approaches—both in
establishing the elements of a stable approach and
in decision-making about whether to proceed with
a landing.
s Inadequate fuel management—mainly in flight
planning, checking and monitoring for general
aviation pilots (we’ll be picking up this issue in one
of our ‘avoidable accidents’ series).
We’ll be keeping a close eye on emerging safety
concerns and others as they begin to form and will
keep you informed of any developments.
In the meantime, don’t forget to follow us on Twitter
(@ATSBinfo) to ensure you’re kept up to date with our
investigations and safety advice.
Turramurra investigation
explores multiple factors
M
ost people think there is only one major cause to an accident,’
explains Nev Blyth, the ATSB’s Manager of Technical
Analysis. ‘Most of the time though, these events are extremely
complex, with multiple factors combining in sometimes unforeseen
ways.’ As a result, accident investigations must painstakingly examine
all elements of the occurrence. An example of this holistic approach
is the ongoing investigation into the fatal helicopter accident near
22 July 2011, claimed the lives of two people when a Bell 206L
helicopter collided with terrain. ATSB Investigators are analysing
numerous possibilities to unravel what ultimately led to the accident,
and gain as complete an understanding as possible.
To begin with, analysis of the wreckage distribution and key
components has indicated that a section of the helicopter’s tail
preliminary indications of failures or pre-existing conditions that
could have brought about the tail boom strikes.
Meanwhile, ATSB investigators are analysing weather forecasts and
local observations to develop an appreciation of the local conditions
and the variability of the weather around the time of the accident.
Witnesses reported low cloud and rain showers in the area.
surveillance records and recordings of radio communications between
to obtain information from recovered on-board GPS navigation
equipment. Although seriously damaged in the accident, the
equipment may provide additional and potentially valuable detail on
Finally, investigators are conducting interviews with witnesses to
human factors investigator has been assigned to the team.
Findings from all these avenues of inquiry will be combined in the
the accident as possible.
Martt in Dolan
Martin
Chief Commissioner
May 2012. Q
(]PH[PVU:HML[`0U]LZ[PNH[VY
Lake Eyre investigation yields a preliminary report
T
he ATSB has released its preliminary
report into the fatal helicopter
accident which occurred near Lake
Eyre in South Australia.
On 18 August 2011 the pilot and two
passengers of the aero helicopter were
television documentary. At about
5.15 pm, the helicopter landed on
an island in the Cooper Creek inlet,
about 145 km north
of Marree, so that
they could meet and
interview a tour group.
an investigation. A team of four was
convened in Adelaide, with investigators
Mechanical Engineers (LAMEs), an
electronics specialist, and a generalist
investigator. From Adelaide, they
travelled to Marree, which would form
the base of operations.
thing that had no interest in giving any
shade.’ Nevertheless, the investigators
were fortunate with the weather.
especially if they’ve been burned. To
protect themselves, the investigators wore
‘bio-suits’ – blue plastic suits that are
disposable. When working in the heat,
the suits can make an uncomfortable
day almost unbearable.
Other equipment
included basic toolkits
for the two LAMEs, as
information on CD that
the manufacturers had
provided.
well before 7.00pm,
when the helicopter
departed the island.
group advised authorities of what they
had seen and initiated a search. Later that
night, they located the helicopter, about
3 km from the departure point. A trail of
wreckage 60 metres long stretched out.
and two passengers died in the accident.
sharing updates with
the headquarters in
Canberra, as well as
making arrangements
site,’ recalls Rob Chopin, ATSB Senior
Transport Safety Investigator. ‘Basically,
the only way in and out of the site was by
helicopter.’ During the on-site phase of
the investigation, the team would make
four return helicopter trips to the site,
about 3 km from the Cooper Creek Inlet.
An undulating landscape, consisting of
sand dunes and low scrub, the site itself
presented its own challenges.
two engines the engines would need to be
examined under the supervision of ATSB
investigators, along with various other
components including the GPS, which
had been damaged by the impact.
Using these recovered materials, the
observations gathered at the site, and the
input from witnesses and background
research, the investigators will work to
12 months.
‘We took enough materials to make a
was 500 metres away, and was a thorny
is available on the ATSB website
www.atsb.gov.au Q
ATSB
‘Communications was
our biggest problem,’
explains Chopin. ‘Marree
itself did not have
mobile coverage, so all
of our connections had
to be made via satellite
intending to return to
their accommodation at
a property about 48 km
north of Marree. One
witness overheard the
occupants discuss the
option of looking at the
lake when airborne.
A number of witnesses
from the tour group saw
Photo of accident site
the helicopter depart
in an easterly direction before turning to
the north. Several also reported seeing
the helicopter descend before going out
53
The ATSB is seeking your views on
Confidential Reporting
O
ne of the main beliefs of the
ATSB is that it is more important
to pursue safety outcomes than
their feedback on the scheme, and what
changes, if any, they would like to see
your comments to help us have the best
scheme in place. We are particularly
interested in any concerns you have about
the proposed reforms—whether you agree
with the new regulations or would like to
see more changes.’
principles are embodied in the legislation
that underpins the ATSB’s investigation
role: the Transport Safety Investigation Act
2003.
While organisations within the transport
industry should provide their employees
with the opportunity to report their
concerns without fear of any reprisal,
some may not, or may not do so
54
relevant documents and contact details
can be found on the News area of the
ATSB website at www.atsb.gov.au. Any
comments need to be submitted by
16 December 2011.
safety concern goes unreported, the ATSB
by the ATSB are important because they
FSA NOV-DEC 2011
All parties are given an opportunity
to provide comment on responses.
(REPCON) scheme enables any person
to report an aviation safety concern to
the ATSB. Steve Young, Manager of
‘completed’ with all personal details
permanently removed from the REPCON
at the ATSB says: ‘A “reportable safety
REPCON brief in Flight Safety Australia.
Now, however, the REPCON scheme is
reportable under the mandatory reporting
issues such as organisational matters,
poor or inadequate procedures relating to
training, maintenance, rostering, etc.’
to the appropriate organisations in order
to highlight safety issues that might
otherwise remain unreported. Protection
of the reporter’s identity, and any person
named in the report, is a core element of
the scheme. A report must contain the
reporter’s contact details before it will be
accepted as a REPCON.
Key dates to remember
maritime schemes are being consolidated
while including a scheme for rail for the
The scheme provides de-identified
reports to the appropriate organisations
in order to highlight safety issues that
might otherwise remain unreported.
Reportable Safety Concerns that meet
established under the Transport Safety
Act 2003,’ explains John Taylor, Principal
Lawyer at the ATSB and manager of the
REPCON reform project. ‘As a result,
by removing all personal references and
reporting will be “Restricted Information”
can proceed further. Once authorised,
have the same substantial protections as
information that is generated or obtained
through our safety investigations.
responsible organisation for action as
deemed appropriate. CASA will comment
on any action taken by the organisation.
transport safety without fear of reprisal
or sanction. Some of the matters reported
are considered serious issues, and some
may be less so. But all reports are assessed
and handled sensitively, because the ATSB
would far prefer to prevent an accident
than have to investigate one. Q
opportunity for stakeholders to give
The consultation on the draft
regulations for confidential reporting
closes on 16 December 2011.
The ATSB plans to hold a second round
of consultation with stakeholders in
early 2012. The ATSB plans for the new
Regulations to take effect in 2013.
More information
If you have any questions about the
new confidential reporting reforms,
email repconreform@atsb.gov.au or
call John Taylor on 02 6274 6416.
Providing comments
To provide comments on the proposed
Regulations, we recommend you
first read the Confidential Reporting
Discussion Paper and Explanatory
Statement. These are available from
the News area of the ATSB website
www.atsb.gov.au. Those documents
help explain the proposed regulations.
You can submit your comments by
email to repconreform@atsb.gov.au
Investigation briefs
Emergency location issues
divers found that, as a result of the impact
Investigation AO-2011-055
accident.
An accident involving an R44 helicopter,
and the issues surrounding the
subsequent search and rescue, have
prompted warnings about the importance
of programming and testing emergency
locator transmitters.
When installed, an ELT must have
been programmed with a unique
into three separate pieces.
ELTs need to be registered with the
Australian Maritime Safety Authority
(AMSA), so that AMSA’s RCC can
the northern shore of the lake. Neither
On 30 April 2011, the owner–pilot of
the helicopter was conducting a local
Kilmore Gap, Victoria. During low-level
manoeuvring at low speed around a dam,
the pilot lost directional control and
was seriously damaged; the pilot and
passenger sustained minor injuries.
accident.
can be directly programmed before
a programming dongle in the wiring
that in this occurrence the ELT had
been inadvertently reprogrammed with
incorrect information from the dongle.
In response, CASA published
Airworthiness Bulletin 25-018 to alert
maintenance organisations to the risk
of programming dongles transferring
potentially invalid details to the memory
low that the wingtip contacted the surface
of the water could not be established
unlikely that the pilot deliberately ditched
55
any initiating cause. Regardless of the
reason for being at low level, it is probable
that the pilot misjudged the height of the
distracted at a height from which the pilot
impacting the water.
activated the emergency locator
transmitter (ELT), which broadcasted ‘a
cry for help’ on the 121.5 MHz and 406
MHz frequencies. However, the 406 MHz
transmission that was monitored by the
search and rescue (SAR) agency did not
The dangers of low-flying
information. As a result, there was no
On the morning of 21 June 2010, the
owner–pilot of a Cessna 172N, registered
VH-UFN, departed from a private airstrip
near Woolcunda Lake, New South Wales
transmission on 121.5 MHz , but as it
turned out, the satellite system used by the
rescue coordination centre (RCC) had not
been receiving alerts on that frequency
since February 2009.
Fortunately, pilots of a number of
Investigation AO-2010-045
A fatal accident at Woolcunda Lake
has served as a tragic reminder of the
heightened risk that surrounds low-level
operations.
organisational or systemic issues that
aviation operations. However, the accident
does provide a timely reminder of the
heightened risk associated with low-level
operations, especially over expanses of
report AR-2009-041 Avoidable Accidents
addresses the
reported missing to authorities.
transmission during routine monitoring,
emergency locator beacon (ELB) and a
SPOT Satellite Messenger (SPOT), but
which mobilised the crew of a search and
on the 121.5 MHz signal, and arrived at
ATSB
advised that they were introducing
measures to increase awareness of
programming dongles in their new
helicopters. Q
located in Woolcunda Lake, in deep water
towards the centreline of the lake. Police
and in particular, the reduced time
available to recover from any loss of
free on the ATSB website
www.atsb.gov.au Q
Bad procedures top aviation safety concerns
P
continue to pose the biggest risk to
aviation safety, according to a new
ATSB research report.
Why procedures matter
Case study 1: Emergency checklist
Investigation AO-2008-003
investigations conducted by the ATSB in
2010–11. (Safety issues are factors that
operations).
Overwhelmingly, the majority of safety
issues related to poor or inadequate
56
by operators of high capacity and other
passenger operations, covering a wide
range and variation of procedures.
On descent to Bangkok International Airport, a Boeing 747 experienced a substantial water leak in the forward galley. The cockpit indications progressively showed a
number of electrical power-related malfunctions. Many of the aircraft’s communication, navigation, monitoring and flight guidance systems were affected. The aircraft
eventually landed safely at Bangkok Airport.
One of the major findings of the investigation reveals that the operator’s Quick
Reference Handbook for flight crew did not include sufficient information for flight crew
to manage an electrical system emergency. This lack of procedural information resulted
in the flight crew relying on their recollection of systems knowledge to assess and
manage numerous failures with a limited amount of time available before the batteries
were depleted. The investigation concluded that a checklist would have increased the
consistency of crew actions in such emergencies.
FSA NOV-DEC 2011
ATSB Chief Commissioner, Mr Martin
Dolan, said this is an alarming result
the top aviation safety risk in last year’s
report.
inadequate aviation procedures accounted
safety,’ Mr Dolan says.
‘I remind operators that good standard
operating procedures remain one of the
best defences against aviation accidents.’
Main equipment centre
Example corrosion on the GCU 3 circuit board (arrowed)
Case study 2: Hover height
Investigation AO-2009-068
pilots are very reliant on adequate and
accessible procedures to ensure they can
issues that can arise during operation.’
Safety issues and safety actions
is
available on the Safety Awareness area of
the ATSB website at www.atsb.gov.au. Q
During a rescue operation, a Bell helicopter 412 approached the winching area of a
ship while lowering a rescue crew member and paramedic. When the pilot lost sight
of the ship’s landing area the helicopter began to drift and the pilot was unable to stop
the helicopter’s movement. The winch cable separated from the helicopter resulting
in the rescue officer and the paramedic falling 10 metres to the ship’s deck. Both were
seriously injured. The investigation found that the operator’s winching procedure
did not require the pilot to confirm an adequate hover reference before deploying
personnel on the winch.
REPCON briefs
Australia’s voluntary confidential aviation reporting scheme
REPCON allows any person who has an aviation safety concern to report it to the ATSB
confidentially. All personal information regarding any individual (either the reporter or any
person referred to in the report) remains strictly confidential, unless permission is given by
the subject of the information.
The goals of the scheme are to increase awareness of safety issues and to encourage
safety action by those best placed to respond to safety concerns.
REPCON would like to hear from you if you have experienced a ‘close call’ and think others
may benefit from the lessons you have learnt. These reports can serve as a powerful
reminder that, despite the best of intentions, well-trained people are still capable of making
mistakes. The stories arising from these reports may serve to reinforce the message that we
must remain vigilant to ensure the ongoing safety of ourselves and others.
Gable markers
Report narrative:
that aerodrome gable markers used at the
aerodrome on certain taxiways are not
taxiway markers, but aerodrome gable
markers, and as such, do not conform to
standard taxiway marker requirements.
with unserviceability markers 4 weeks ago
to note that the area is no longer suitable
conducted October 2009 noted that
Taxiways B and D have a width of
minimum taxiway width of 10.5 metres
Response/s received:
REPCON supplied the operator with the
their response:
an organisational culture which is
and procedures in place are integrated
into day to day business and followed by
the just culture philosophy is integrated as
an organisational norm.
All safety reports are analysed, risk
rated and actioned as appropriate on a
57
through procedural documentation and
also informally through various safety
communication mechanisms.
REPCON supplied CASA with the
provide the required lateral taxiway
clearances, and may result in an incident.
clearance requirements were not being
requirements. Again, gable markers have
been used immediately adjacent to the
sealed area of the taxiway.
It is reported that an ex-CASA aerodrome
inspector has surveyed the area in
CASA has since reviewed this matter.
REPCON supplied CASA with the de-
the penalties for reporting safety issues
CASA is unable to address these concerns.
their response:
implement a CASA approved safety
management system (SMS) which includes
safety reporting processes. During
recent surveillance conducted on the
operator’s SMS we found no evidence that
supports neglect in encouraging safety
reporting and in taking action on reported
discrepancies to satisfy regulatory
obligations.
have been removed and the “Parking
Clearance” line in between taxiways B3
and D2 have been obscured with black
paint so as to provide the appropriate
taxiway strip width for a code B taxiway.
CASA on this matter.
standards have not been met.
Safety management system
Safety reporting is a fundamental
Response/s received:
REPCON supplied the operator with the
Report narrative:
and airline employees are obligated to
utilise the safety reporting procedures
within the SMS and by the operator’s
administration manuals.
their response received:
With reference to this report please be
aware of the following points:
Taxiway B2 and D2 did have yellow gables
taxiing on D2 that there was a corner
that the operator’s pilots are losing faith
with the company’s safety management
instances where pilots had been
reportedly penalised for reporting safety
reporter is also concerned by the lack of
action or basic follow up on safety reports.
How can I report to REPCON?
Online: www.atsb.gov.au/voluntary.aspx
Telephone: 1800 020 505
Email: repcon@atsb.gov.au
Facsimile: 02 6274 6461
Mail: Freepost 600
PO Box 600, Civic Square ACT 2608
ATSB
between taxiways B2 and D2 was
believed to be narrower than the required
standard. It is also believed that the
gable markers that are placed on either
side of this taxiway do not meet the
standard taxiway marker requirements,
their response:
The final
piece of
the puzzle
FSA NOV-DEC 2011
58
Fifty years ago, a
dramatic and puzzling
Australian airline
accident led to the
introduction of what
could be described as
the final ‘jigsaw piece’
in the evolution of our
safe airways system.
Other ‘pieces’ essential
to all-weather flying—
aviation meteorological
services, air traffic
control, radio
communications and radio
navigation aids allowing
aircraft to navigate
accurately in cloud—had
been progressively set
in place over the past
30 years. But one vital
lesson remained, as
Macarthur Job writes.
Top to bottom:
s$ISINTEGRATEDWRECKAGEOF6(46#RAISEDFROMTHEBEDOF
Botany Bay by Navy divers working from HMAS Kimbla.
s4HEFRAGMENTEDWRECKAGEBEINGSYSTEMATICALLYLAIDOUTON
the floor of the Department of Civil Aviation's hangar at
Sydney Airport during the investigation.
s$AMAGEINCURREDATTHEINBOARDENDOFTHESTARBOARDOUTER
wing as aerodynamic forces tore it away from the aircraft.
The Ansett-ANA Viscount 720, VH-TVC, photographed at Melbourne’s Essendon Airport five months before its fateful last flight.
An eerie premonition
Ansett-ANA’s s flight schedule on Thursday, 30 November
1961 for VH-TVC, one of its state-of-the-art turboprop
Vickers Viscount 720s, was surprisingly light—only three
trips between Sydney and Canberra—the relatively short
distance of 130 nautical miles. The day return trip to
Canberra, though rough, was without incident, and TVC
landed back at Sydney Airport just on 6.45pm.
The crew rostered for the 7.10pm flight back to Canberra,
where the Viscount would remain overnight, comprised
Captain S.A. Lindsay, First Officer B.A. Costello, and flight
attendants Aileen Keldie and Elizabeth Hardy.
On her way to the canteen for her evening meal before
boarding TVC, Hardy commented to another flight attendant
on the ‘terrible weather’, saying she was glad she was ‘going
on a Viscount tonight’. Tongue-in-cheek, she remarked:
‘I think I’ll ring Canberra and tell them we aren’t coming’.
At around 6pm, Captain Lindsay went to the airport briefing
office. The meteorological officer gave him the route
forecast and briefed him on the active front approaching
Sydney from the west. Radar returns showed cloud
tops extending to 35,000ft, and pilots were reporting
exceptionally severe turbulence.
Wild weather
‘Don’t be silly,’ Schmidt retorted with a laugh, ‘off you go.’
But as the two flight attendants moved to the door, Hardy
called back: ‘Now don’t forget. If something does happen,
tell Helen and my mother.’
The cabin was configured for 48 passengers, but only
11 were booked on the flight. All but two were Canberra
residents—a gynaecologist at the Royal Canberra Hospital,
two civil servants, an army major, three Canberra company
managers, the wife of another Canberra medical
practitioner, and a self-employed businessman. The other
two were an oil company representative who had been
attending a conference, and a soldier on his way to the Royal
Military College.
Cleared for take-off
At 7.05pm Costello called Sydney tower for a start-up
clearance. Five minutes later, the tower cleared TVC to
runway 25 for take-off into the southwest. Because of the
heavy cloud and rain, the taxiway and runway lights were
already on, and the tower issued the Viscount with an
amended airways clearance.
To avoid inbound traffic, this required a departure track of
244 oM until 37nm DME from Sydney, and thence to Canberra,
cruising at flight level 160 (16,000 feet).
At 7.16pm the controller cleared TVC for take-off, instructing
the crew to maintain runway heading to 3000ft, then to turn
left to pass ‘over the field, not below 5000ft’. The aircraft
took off normally, its navigation lights being lost to view as it
entered heavy cloud at about 800ft. The controller logged the
time as 0917 GMT, 7.17pm local.
Communication lost
When Lindsay returned to the terminal, the two flight
attendants were waiting to board VH-TVC. The Viscount was
parked on the rain swept tarmac just outside, and Costello,
sheltering under an umbrella, was making a pre-flight
inspection with a dispatching engineer.
Five minutes later, the controller offered the aircraft a
choice of two departure tracks; the original track Lindsay
had nominated, or a 217o track that would avoid an extensive
storm cell. Costello’s voice came back, ‘Thank you, we’ll
take the 217.’ The controller instructed the aircraft to ‘report
setting course’.
The two women were joined for a moment by flight
attendant Dagmar Schmidt, another trainee. She had been
a member of the Viscount’s crew on the late afternoon
flight from Canberra. Hardy asked what the trip had been
like. ‘Extremely rough,’ Schmidt told her. ‘The worst I’ve
experienced.’ Concerned, Hardy replied, ‘I’ve got a feeling
The aircraft did not call as expected, and at 7.25pm the
controller transmitted: ‘Tango Victor Charlie, have you set
course yet?’ There was no reply. Further calls also failed to
elicit a response, so the controller, believing the aircraft had
suffered a radio failure, contacted the senior controller to
introduce the uncertainty phase of search and rescue.
59
PIECE OF THE PUZZLE
It had been a wild day in Sydney, with heavy rain, blustery
westerly winds, thunder and lightning. Conditions seemed to
be worsening, and Hardy, only three weeks with the airline
and still under training, felt nervous. Her attitude was not
helped by the vivid dream Keldie had recounted a few days
before. In the dream, they were the only cabin occupants
of a Fokker Friendship that crashed on landing and, as they
left the wrecked aircraft, they saw one of the pilots slumped
over the controls, apparently dead. They had joked about it;
nevertheless they found it disturbing.
something’s going to happen tonight.’ As she picked up her
bag she added: ‘If anything should happen tonight, will you
tell my sister and my mother?’
But when no sign of the Viscount could be detected on radar,
this was upgraded to the alert phase. The situation was
reported to the police, the RAAF, the RAN and the Volunteer
Coastal Patrol. Coastal shipping was alerted, and an air-sea
rescue launch set out to sweep of the foreshores of Sydney’s
Botany Bay.
It was still possible the Viscount was continuing in
accordance with its flight plan, and in the absence of any
reports of an aircraft in trouble, the senior controller could
do nothing more for the time being. Canberra ATC was
informed that communication with the Viscount had been
lost, and Canberra tower stood by to await its arrival. But by
VH-TVC's ETA of 8.05pm, there was no sign of the Viscount.
The distress phase was introduced, but there were still no
reports of anything suggestive of an accident.
FSA NOV-DEC 2011
60
At 9.36pm, the ASR (air sea rescue) launch radioed it
had circled Botany Bay without seeing any wreckage.
Considering the population density in the area, there could
be only one inference; TVC had somehow come down in
the sea.
At first light, aircraft began scouring the open sea off the
coast, while a helicopter and motor launches, braving the
wild weather, searched the waters of Botany Bay. At 6.30pm
the helicopter, investigating an oil slick near the northeastern shore of the bay, sighted what looked like a floating
cushion. The ASR launch recovered it, and airline staff
identified it as upholstery from the Viscount’s cockpit.
Grim evidence
Meanwhile, ground searchers checking the north-eastern
beaches of Botany Bay came upon small items of cabin
furnishings washed ashore—and human remains. At about
8.30am, RAN divers boarded the ASR launch to check
some smaller oil slicks on the southern side of the bay.
Visibility was poor because of the rain, but presently a
police launch drew the divers’ attention to an aluminium
structure protruding from the water not far away. It was the
tip of a wing. Lying in about five metres of water, it bore the
registration VH-TVC.
Meanwhile, near where the upholstery had come to the
surface, police divers recovered a blood-stained seat
cushion, cabin fabric, and more human remains. Further
upwind, the divers came upon the disintegrated main
wreckage scattered over the seabed in eight metres
of water.
The investigation begins
With the remains of all the victims accounted for, the
wreckage was taken to the Department of Civil Aviation's
(DCA) hangar at Sydney Airport. By Thursday, all the heavier
wreckage had been recovered, but it took a further month of
careful underwater searching to find the starboard tailplane
and elevator.
Some 85 per cent of VH-TVC's structure had now been
recovered, examination showing that while the starboard
outer wing and tailplane components had sustained
little impact damage, the remainder of the aircraft had
disintegrated.
To determine the reason for the break-up, the outer
starboard wing spar and the tailplane structure were
examined in detail. There was no sign of fatigue or stress
corrosion; the wing spar had failed purely as a result of
aerodynamic overloading and the resulting forces on the
tailplane caused it to fail almost simultaneously. The port
tailplane was distorted and bent upwards, the mode of
damage showing this occurred as a result of aerodynamic
loads far in excess of normal. Other structures and systems
showed no evidence of malfunction before the break-up, nor
was there any sign of fire. The engines were running when
they struck the water, calculations based on propeller blade
angles indicating the aircraft’s speed was at least 300kt and
possibly as high as 400kt.
Analysis of the wreckage trail showed the Viscount was on
a northerly heading about 1nm south of the position of the
main wreckage, and at between 3500 and 5500ft, when it
broke up. Residents around Botany Bay reported hearing
unusual noises, and it seemed probable that the noises they
described between 7.20 and 7.30pm were either the in-flight
break-up or the aircraft hitting the water.
What happened?
TVC was fully serviceable, and the crew highly experienced.
The only explanation appeared to lie with the violent
weather. Indeed, the 29,000-ton P&O Orient liner Orcades,
Sydney-bound off the coast at the time, had been battered
by a sudden fierce storm soon after receiving a radio
message to keep a lookout for wreckage. The ship’s master
said it was the first time he had experienced ‘that type of
weather in these waters’.
A depression of 1001mbs was centred just north of Sydney
at the time, moving east-southeast. East of it was a warm,
moist, unstable airflow, conducive to the build-up of
thunderstorms.
The cold front to the west extended for 300km. Large
thunderstorms had developed throughout the morning
and afternoon, the activity increasing as the centre of the
depression approached. Between 6 and 8pm, two major
thunderstorms, 25km apart, were over the metropolitan
area. The more northerly storm crossed the coast northeast
of the city, while the other storm did so 10km south of the
airport. Although it was not raining heavily at the airport,
extremely heavy rain fell a few miles further south. Aircraft
approaching Sydney before TVC’s departure reported
severe turbulence.
Investigators agreed the only tenable explanation was a
loss of control resulting from an encounter with ‘unseen
turbulence of extreme magnitude’. That a modern, highperformance airliner, in peak operating condition and flown
by an experienced crew, could so unexpectedly be overtaken
by total disaster in a matter of seconds, simply because it
had flown into turbulence in cloud, was profoundly
disturbing. Decisive measures were obviously needed to
prevent a repetition.
The vital ‘missing link’
Airborne weather radar was now available. Qantas Super
Constellations were fitted with it, as were the airline’s newly
delivered Boeing 707s. An air navigation order was issued
requiring all turbine-powered aircraft on the Australian
register to carry weather radar by 1 June 1963. Thus the
final ‘missing link’ in electronic navigation aids necessary
for the safe conduct of all-weather airline operations was
put in place.
There was a great deal of evidence to support the possibility
that a temporary loss of control resulted from a very severe
gust, causing a sudden upset in attitude. With the crew
unable to correct it before the aircraft lost substantial height,
there would have been a rapid gain in airspeed. The problem
would have been compounded if a close lightning flash had
simultaneously affected the crew’s vision.
But was this enough? Could ATC also assist aircraft to avoid
severe turbulence? There was an obvious need for more
exchange of information between weather bureaus and ATC.
The result was the introduction of a cooperative system
under which areas of storm development, displayed on highly
sensitive weather radars at meteorological bureaus, were
passed to ATC centres, to be superimposed on radar displays
used by air traffic controllers. This enabled controllers to
see where turbulence was likely to be at its worst and direct
aircraft accordingly.
Two and a half years before in Maryland, USA, a Viscount
had broken up in the air in strikingly similar circumstances.
The US Civil Aeronautics Bureau concluded that ‘... a loss of
control ... in extreme turbulence, resulting in an involuntary
In conjunction with weather radar fitted to aircraft, this
system would vastly reduce the likelihood of encounters with
turbulence of the severity that caused the tragic loss
of VH-TVC.
Loss of control
61
PIECE OF THE PUZZLE
Because heavy rain also fell to the north and east of the
airport about the time of the accident, the investigators
believed a new storm cell was probably developing
directly in the path of TVC as it climbed to set course to the
southwest. At the time communication was lost, it would
have been about 2nm southeast of the airport at a height
of around 6500ft, climbing at 165kt. Between this point and
the structural failure three minutes later, something violent
happened, causing the Viscount to suddenly lose as much
as 3000ft and increase its speed to perhaps 400 kt. TVC,
flying on instruments, probably encountered a gust of
unusual intensity.
steep descent, following which aerodynamic loads from
high speed recovery and turbulence exceeded the design
strength of the aircraft,’ had occurred.
WHEN IT’S TIME TO GO
FSA NOV-DEC 2011
62
Cabin crew, like pilots, spend most of their training
in preparation for emergencies
Riding an escape slide from the main deck of a widebodied aircraft is a serious, frightening experience, even
on a training rig. This is the moment that cabin crew train
years for: serving food and drinks only supplements
their real jobs – safety and rapid evacuation specialists.
The cabin crew who welcome passengers aboard, help
them stow all their cabin baggage and serve tea or coffee,
are the last line of defence in an emergency.
Australia’s excellent safety record fortunately means
that all the experience gained in airlines’ six-monthly or
annual evacuation drills rarely has to be put into practice
in this country. There are so few accidents it can be hard
to convince travellers that safety matters. In contrast, in
the U.S, according to a National Transportation Safety
Board report in 2000, emergency aircraft evacuations
happen about once every 11 days. In many of these, the
main hazard to passengers proved to be using the slide.
In 2006, when a new Airbus A380 underwent mandatory
evacuation tests, considered successful, thirty-three of
the 873 volunteers were hurt. One volunteer suffered a
broken leg and 32 received slide burns.
Passenger behaviour in an emergency evacuation can
dramatically effect their survival chances. Experienced
flyers can be blasé about safety briefings, but not listening
means that the correct procedures will not be top of mind
if there is an emergency, and so such passengers may
behave inappropriately, or ignore the directions of cabin
crew. However, they could also be more at ease with
flying and therefore calmer in a crisis. Inexperienced
flyers may panic or freeze and can be a particular liability
if they are in an exit row.
Two Boeing 737 accidents in the 1980s illustrate this
contrast. Both involved engine fires that spread to the
rest of the plane. In the first, in Calgary, Canada, in 1984
all the passengers and crew evacuated within ninety
seconds and escaped with only five serious injuries. In
the other, in Manchester, England, 55 of the 137 people
on board died. Passengers were still trying to get out
after three minutes, by which time the concentration
of smoke and toxic chemicals in the cabin was at an
incapacitating level.
A difference between the two flights might have been that
the Calgary passengers were mostly business travellers,
while in Manchester they were mainly tourists who
rarely flew.
Australians are taking to the skies in much greater
numbers, so the distinction between business travellers
and tourists is being replaced by a division into frequent
flyers of assorted hues and shines, with varying levels
of attention to safety-related issues. The cabin crew
manager of a regional airline mentions an interesting
spin-off of the mining boom. She has noticed that OH&S
training staff are very good at reminding workers to pay
attention to safety briefings, and many mining companies
now run their own evacuation drills.
About 71 per cent of aviation fatalities occur after the
aircraft has crashed or made a forced landing, and about
80 per cent of all aviation accidents happen shortly before,
after, or during take-off or landing, with the majority
on landing.
‘Ditching can be controlled and deliberate due to aircraft
systems failure (e.g. the Hudson River dual engine failure);
or unexpected, as in a rejected take-off with the aircraft
over-running the runway into water (many airports are
built jutting out into a bay or lake because reclaimed land
is cheap).
‘The important point with ditching is that once the aircraft
comes to rest the cabin crew automatically launch the
rafts, without instruction from the flight crew, because
communication systems are often disabled by water.
‘Land evacuation is usually initiated by the captain (unless
the tech crew are fatally injured) and may be planned in
circumstances such as an engine fire and return to land.
However, unexpected events such as a rejected take-off
‘On the captain’s initiation of a land evacuation, the flight
crew make sure the cabin is not pressurised and shut
down all engines, leaving only a single battery circuit to
operate emergency exit lights, floor passenger guidance
lights and emergency PA. The cabin crew then assess
exits, open doors and initiate evacuation procedures.
‘Before every take-off we have a discussion about
potential engine failure and return to land, and mentally
rehearse what we would do.’
Assertiveness saves lives
The response and behaviour of the cabin crew
significantly affects how passengers perceive the level
of danger and react to it. Using short concise commands,
in an assertive tone, with positive exaggerated gestures
and physical contact to encourage people to move as
quickly as possible will give passengers confidence and
result in a better organised and more efficient evacuation.
Even if some passengers do not speak English they will
understand clear and strong hand signals.
Cabin crew also need to be very clear and assertive when
briefing exit row passengers, who may be the difference
between life and death for fellow travellers as well as
themselves. Exit row seats should not just be a reward for
frequent travellers.
‘I asked a passenger in an exit row to stop using his phone,
switch it off, and listen to the briefing, but he just went on
talking’, says cabin crew member Shelley.
Confusion at exits and a passenger’s inability to open an
exit door, contributed to the loss of life in the Manchester
accident mentioned previously. Australia has always been
aware of ensuring that the most appropriate, physically
63
WHEN IT'S TIME TO GO
Evacuations can follow a ditching or a forced landing,
as well as a crash. Stewart, a senior pilot with a major
Australian airline, says that:
with runway over-run might lead to a partial gear collapse
that renders some exit doors unusable because the
aircraft comes to rest at an odd angle.
capable people are seated in exit rows. In recent years,
many airlines have screened passengers to ensure
that exit row seats are allocated to able-bodied adults
who are fluent in the carrier’s native language, but, as
Shelley says:
‘I actually had an entire family, with two children under
seven, as the last to board. Their seats were all in an exit
row. Not only that, but they couldn't speak English.
‘It used to be that people could only be in exit rows if they
fronted up to a check-in desk, but now they can self-check
at a kiosk. If we don't catch it at the boarding readers, the
onboard manager should catch it at the door; and the last
line of defence is at the briefing, where we are making sure
people have read the card, are listening, can understand –
and are likely to be able to cope in an emergency.
FSA NOV-DEC 2011
64
‘The other day, I briefed an exit row, and when I explained
that the exit weighs 27kg, and please let me know if you
might have any difficulties with throwing that weight,
one lady said “that sounds heavy”. I said, “Yes, it's about
the weight of a large suitcase”. She didn't really want to
change seats, and then said, “Oh I'll be fine, it probably
won't happen anyway”. But because she had mentioned it
might be an issue, I was obliged to move her.
7ZRUHFHQWKLJKSURÀOH
aviation accidents have also
been triumphs of successful
evacuation decision-making.
QF32: successful controlled disembarkation
using stairs
Check captain Dave Evans said the most serious part of
the engine explosion on QF32 in Singapore came after
the landing, when the pilots had to decide whether to
evacuate. Fuel was leaking from the left wing and the
maximum braking used during the landing made brake
temperatures soar to 900°C.
The aircraft was on battery power and the crew had use
of only one VHF radio dedicated to the fire commander,
who was reluctant to send his crew near the plane with an
engine still running and fuel pouring onto the hot brakes.
‘We had 433 passengers onboard: we had elderly people,
we had wheelchair passengers, so the moment you start
evacuating, you are going to have injuries. Deploying a
slide before an evacuation had been deemed necessary,
and is also unwise,’ Evans told the Royal Aeronautical
Society. ‘Should the outside conditions become dangerous
you have no way to reverse that, and you are leaving an
entry point for smoke/fire into the cabin. There is no point
in throwing elderly and/or disabled people down slides,
where injuries are a given, unless things deteriorate to a
point where life is in danger. At that time, deploy the slides
and evacuate by any and all necessary means. Then, and
only then, are broken limbs and cracked heads worth
the risk.
‘We had fuel, hot brakes and an engine that couldn’t be
shut down, so really the safest place was on board the
aircraft until things changed.
‘The cabin crew was in alert phase the whole time, ready
to evacuate, open doors, inflate slides at any moment. The
danger gradually abated and, thankfully, we were lucky
enough to get everybody off very calmly and methodically
down one set of stairs.
‘The cabin crew kept anxious and increasingly hot
passengers calm and under control, not only in the air,
but also on the ground, while they waited for the stairs
to arrive. This accident shows the value of training,
experience and the most professional type of CRM (crew
resource management).’
US1549: ‘The most successful ditching in
aviation history’
US Airways Flight 1549 successfully ditched in the
Hudson River near midtown Manhattan six minutes after
take-off from LaGuardia Airport, after being disabled by
striking a flock of Canada geese. All 155 occupants safely
evacuated the aircraft, which was still virtually intact
though partially submerged and slowly sinking, and were
quickly rescued by nearby watercraft.
About 90 seconds before touchdown, the captain
announced, ‘Brace for impact’, and the flight attendants
instructed the passengers how to do so. Immediately after
the A320 had been ditched in mid-river, the pilot gave
the ‘evacuate’ order over the PA, and the aircrew began
evacuating the 150 passengers, both onto the wings
through the four mid-cabin emergency window exits, and
into an inflatable slide that doubled as a life raft.
This was deployed from the front right passenger door
(the front left slide failed to operate as intended), while
the partially submerged and slowly sinking airliner drifted
down the river with the current. Two flight attendants were
in the front and one in the rear.
Each flight attendant in the front opened a door, which
was armed to activate a slide/raft. The port side raft did
not immediately deploy so a manual inflation handle was
pulled. One rear door was opened by a panicking passenger,
causing the A320 to fill more quickly with water.
Silent review
The common mnemonic for this routine
is OLDABC:
Five people suffered serious injuries, and 73 others minor
injuries and hypothermia.
Things you hope passengers will remember:
Sit up, look up and pay attention to the safety briefing
Read and inwardly digest the safety briefing card
Keep their seat belts fastened while seated
Listen to exit row briefings and understand how to
open emergency doors without blocking the exit
65
Understand the correct brace position
WHEN IT'S TIME TO GO
Don’t be fooled by the unresponsive gazes. When
cabin crew are strapped into their folding seats
for take-off and landing they are thinking of more
than what will be on the menu in that night’s hotel
layover. For every take-off and landing every cabin
crewmember performs a silent mental review. They
go over where they are positioned in the aircraft,
the operation of exits, emergency equipment they
might need to use and those passengers who will
need additional help to evacuate, where able-boded
passengers (who could be useful in an emergency)
are sitting, the appropriate crew brace position and
the signal to commence brace commands, and the
commands they would use to evacuate passengers.
The flight attendant in the rear who attempted to reseal
the rear door was unable to do so because the impact with
the water had ripped a hole in the underside of the aircraft
and twisted the fuselage, causing cargo doors to pop open
and filling the plane with water from the rear. The flight
attendants urged passengers to move forward by climbing
over seats to escape the rising water within the cabin.
Have two evacuation plans – one for the closest exit
and an alternative if that one is unavailable
Count and memorise the number of rows to both exits
Abandon their cabin baggage in an emergency
Have their money and passport on their person
(see point above)
Check for fire before opening emergency exits
Operation of exits
Dispose of the exit correctly
Location of emergency equipment
Wear sensible shoes – open sandals, high heels
and thongs are a hazard in hostile conditions
Drills
Able-bodied passengers and people with a disability
Brace position and signal
Commands – and conditions outside the aircraft
Silent review is an effective way of removing the
distractions that can block situational awareness
and hinder quick responses. As CASA cabin safety
inspector Susan Rice says, ‘It could be the difference
between making the right decision or the wrong
decision’.
Further reading
A Database to Record Human Experience of Evacuation
in Aviation Accidents
www.caa.co.uk/docs/33/2006_01.pdf
Evacuation Commands for Optimal Passenger Management
www.atsb.gov.au/publications/2006/grant_20040239.aspx
Buy duty-free alcohol on arrival at their destination.
Alcohol is flammable and bottles can become
lethal missiles
Wear clothing made from natural rather than
artificial fibres to protect them from flash burns
Help others to evacuate and once clear of the
plane move quickly to a safe distance upwind.
Public Attitudes, Perceptions and Behaviours towards
Cabin Safety Communications
www.atsb.gov.au/publications/2006/b20040238.aspx
CASA Civil Aviation Order 20.11 (as amended)
www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD
::pc=PC_91469
1.
(b) right engine will be most critical because the effective
thrust line of the left engine is further inboard due to
P factor.
When a TAF states: ‘BECMG 0101/0103 BKN ST 1200’ it
means that
(a) at some time between 0100 and 0300 UTC on the 1st, the
forecast cloud will become broken stratus at 1200ft above
the aerodrome level and this will continue until the end of
the forecast period or until the next change in conditions.
(d) left engine will be most critical because the effective
thrust line of the right engine is further inboard due to
P factor.
(b) at some time between 0100 and 0300 UTC on the 1st, the
forecast cloud will become broken stratus at 1200ft AMSL
and this will continue until the end of the forecast period
or until the next change in conditions.
66
FSA NOV-DEC 2011
(c) left engine will be most critical because the effective
thrust line of the right engine is further outboard due to
P factor.
(c) from 0100 to 0300 UTC on the 1st, the forecast cloud will
be broken stratus at 1200ft above the aerodrome level.
5.
(a) increases with increasing height.
(d) from 0100 to 0300 UTC on the 1st, the forecast cloud will
be broken stratus at 1200ft AMSL.
2.
On some light aircraft piston engines there is a red-lined
minimum oil temperature for run-up. This requirement may
imposed because:
(b) decreases with increasing height.
(c) remains the same with increasing height.
(d) increases with height and temperature.
6.
(a) if the oil cooler is on the delivery side of the oil pump,
attempting to draw cold viscous oil through the cooler
may result in pump cavitation and inadequate lubrication.
Compared to a registered aerodrome, a certified aerodrome:
(a) will not have a runway with a non-precision approach.
(b) may have at least one runway with a non-precision
approach, whereas a registered aerodrome will not have
such a runway.
(b) if the oil cooler is on the suction side of the oil pump,
attempting to draw cold viscous oil through the cooler
may result in pump cavitation and inadequate lubrication.
(c) may accommodate operations with aircraft of a larger
seating or carrying capacity.
(c) if the oil cooler is on the delivery side of the oil pump,
attempting to force cold viscous oil through the cooler
may over-pressure the pump.
(d) if the oil cooler is on the suction side of the oil pump,
attempting to draw cold viscous oil through the cooler
may over-pressure the pump.
In a typical normally aspirated piston engine, for the same
percentage of rated power, the fuel flow:
(d) is not suitable for operations with aircraft with a larger
seating or carrying capacity.
7.
On a turbocharged piston engine the manifold pressure is
increased by:
(a) closing the waste gate, which increases the turbine RPM.
3.
With increasing altitude, the minimum single-engine control
speed (VMCA) on a normally aspirated piston twin-engined
aircraft will:
(b) closing the waste gate, which decreases the turbine RPM.
(c) opening the waste gate, which increases the turbine RPM.
(d) opening the waste gate, which decreases the turbine RPM.
(a) reduce and may become less than the stall speed.
(b) reduce but, because the stall speed also reduces with
height, the margin between the two will remain the same.
(c) increase and will occur at a lower margin above the
stall speed.
(d) increase and will occur at a higher margin above the
stall speed.
4.
On a typical piston twin-engined aircraft where both engines
rotate clockwise as viewed from the cockpit, failure of the:
(a) right engine will be most critical because the effective
thrust line of the left engine is further outboard due to
P factor.
8.
One difference between class D and class E airspace is that
in class D
(a) all flights are provided with an air traffic control service,
whereas in class E only IFR aircraft are provided with
this service.
(b) all flights are provided with an air traffic control service,
whereas in class E only VFR aircraft are provided with
this service.
(c) both VFR and IFR flights are permitted, whereas only
IFR flights are permitted in class E.
(d) all aircraft must be transponder-equipped whereas only
IFR aircraft require a transponder in class E.
9.
If two-way radio communications are lost the transponder
code of:
10. The aeronautical information service (AIS) and MET currently
available from the Airservices website under ‘Pilot Briefing’:
(a) 7500 should be set and the controller may establish
whether the aircraft is receiving transmissions by
requesting a selection of code 1200.
(a) will remain in service in parallel with NAIPS for the
foreseeable future.
(b) will remain in service in parallel with NAIPS for the
foreseeable future, but the software version of NAIPS is
no longer supported.
(b) 7500 should be set and the controller may establish
whether the aircraft is receiving transmissions by
requesting operation of the SPI function (squawk ident).
(c) will be decommissioned in 2014, and the service will only
be available via NAIPS.
(c) 7600 should be set and the controller may establish
whether the aircraft is receiving transmissions by
requesting operation of the SPI function (squawk ident).
(d) will be decommissioned in April 2012, and the service will
then only be available via NAIPS.
(d) 7600 should be set and the controller may establish
whether the aircraft is receiving transmissions by
requesting a selection of code 1200.
1.
One safety-related characteristic of lithium-ion batteries
is that, if exposed to high temperatures:
6.
(a) a different diameter cylinder bore on each side.
(a) thermal runaway may occur due to increased internal
dissipation and the battery may burst or catch fire.
(b) a different diameter piston on either side.
(c) a piston rod on one side of the piston only and, as a result,
the force available to extend the rod is reduced.
(b) thermal runaway may occur due to reduced internal
dissipation and the battery may burst or catch fire.
(d) a piston rod on one side of the piston only and, as a result,
the force available to retract the rod is reduced.
(c) the terminal voltage may rise to the point at which damage
may occur to the connected equipment.
(d) the output current may increase to the point at which
damage may occur to connected equipment.
2.
7.
(c) are not damaged by overcharging.
(c) reduce the bending moment of the wing both when
taxiing and in flight.
Antihistamines are a category of drug that may have a negative
impact on a person’s ability to work safely in an aviation
environment and:
(d) increase the bending moment of the wing both when taxiing
and in flight.
8.
(b) may be found in non-prescription medications but are
testable under a CASA DAMP.
(a) compression during taxiing and tension during flight.
(c) are only found in prescription medications.
(b) tension during taxiing and compression during flight.
(d) have effects that are not modified by alcohol.
(b) two-lug anchor nut.
(c) corner anchor nut.
(d) one-lug anchor nut.
5.
(c) tension during all operations.
MS 21080 is the part number of a:
(a) thin self-locking nut.
An aircraft tubing identifier with a green band and identical
rectangles indicates:
(a) instrument air.
(b) fire protection.
(c) breathing oxygen.
(d) water injection.
On aircraft where the undercarriage is attached to the wing
rather than the fuselage, the top spar cap outboard of the
undercarriage attachment is in:
(d) compression during all operations.
9.
The permissible altimeter error at 2000ft under FAR 43 and as
proposed for adoption in Australia via changes to CAO 100.5 is:
(a) ±3%.
(b) ±20ft.
(c) ±30ft.
(d) ±100ft.
10. A constant displacement pump:
(a) will absorb a constant driving power regardless of
output pressure.
(b) delivers a constant pressure regardless of demand.
(c) delivers a volume of fluid per revolution as determined
by demand.
(d) delivers a fixed volume of fluid per revolution of the pump.
QUIZ
(d) do not self-discharge in storage.
4.
Compared to fuel in the inboard main tanks, the structural effect
of relocating the same mass of fuel to the tip tanks is:
(b) to increase the wings’ downward bending moment
when taxiing but to reduce the upward bending moment
during flight.
(b) can be permanently damaged by over discharging.
(a) may be found in non-prescription medications but are not
testable under a CASA DAMP.
67
(a) to decrease the wings’ downward bending moment
when taxiing but increase the upward bending moment
during normal flight.
Lithium-ion battery packs
(a) should be completely discharged when shipping or storing.
3.
Unbalanced double-acting hydraulic linear actuators have:
GNSS RNAV Approach
3.
You are in inbound to Yarram (YYRM) Victoria, tracking from
Wonthaggi (WON) VOR and NDB (Refer ERC 2), in a Beechcraft
B55 Baron (Category B).
(a) You may only use the GNSS RNAV alternate minima
for planning purposes if it is TSO 145/146 or equivalentapproved.
You are GNSSRNAV endorsed and current. The aircraft is
equipped with ILS, VOR, ADF and approach-approved GPS
(current database). The following questions relate to this flight
for the RNAV Rwy 09 (plate dated 12 Mar 2009).
1.
(b) You may use the alternate minima for all GNSS RNAV
equipment that is approach-approved.
(c) GNSS RNAV cannot yet be used for alternate planning
purposes, so YYRM must be treated as ‘No Aid’ alternate
criteria i.e. no more than ‘SCT’ cloud below LSALT + 500ft
and visibility not less than 8km.
At the flight planning stage, you have calculated the LSALT
from WON to YYRM, since it is a non-published track. Which
of the following represents the GNSS method for this LSALT?
(d) GNSS RNAV cannot yet be used for alternate planning
purposes, so YYRN must be treated as ‘No Aid’ alternate
criteria i.e. no more than ‘SCT’ cloud below LSALT and
visibility not less than 5km.
(a)
(b)
68
Approaching 30 GPS to run YYRM on track from WON at 5000ft
in cloud you plan top of descent. You have previously loaded the
Rwy 09 RNAV approach. RAIM is available.
4.
FSA NOV-DEC 2011
Also at the planning stage you consider the alternate
requirement for the ‘No Aid’ aerodrome at YYRM.
Which of the following is correct?
Which of the following is correct concerning the scaling as
you cross 30 miles to run?
(a) The GNSS unit is in ‘Enroute’ mode with a scale of 1nm per
dot until 25miles when it will go to ‘Terminal’ mode with a
scale of 0.2nm ‘per dot’.
(c)
(b) The GNSS unit will change from ‘Enroute’ to ‘Terminal’
mode as you pass 30 miles to run. The scaling therefore
changes from 1 mile to 0.2 mile ‘per dot’.
(c) The GNSS unit will always be in ‘Approach Active’ mode
with a scale of 0.06nm per dot with an approach loaded
into the flight plan.
(d)
(d) The GNSS unit will change from ‘Enroute’ to ‘Approach
Active’ mode as you pass 30 miles. The scaling therefore
changes from 1 mile to 0.06 mile ‘per dot’.
2.
As a back-up LSALT calculation in case a RAIM loss was to
occur, which of the following is the method using VOR/NDB?
(a)
Having passed 25 miles to run you activate the approach to track
direct to YRMWB.
5.
What is the lowest altitude to which you may descent enroute
to YRMWB?
(a) The grid LSALT of 3900ft.
(b) The calculated LSALT between Wonthaggi and Yarram.
(c) The M.S.A. YYRM of 3900ft.
(b)
(d) The M.S.A. YYRM of 2600ft.
Approaching YRMWB on a heading of 105M, you consider the
sector entry and holding pattern if it is required.
(c)
6.
What are the sector entry and holding details?
(a) Sector 1 (parallel) entry, left hand, 1 minute.
(b) Sector 2 (teardrop) entry, left hand, 1 minute.
(c) Sector 3 (straight in) entry, left hand, 1 minute.
(d)
(d) No holding details at YRMWB, therefore you must go
straight into the approach.
7.
If a hold was necessary at YRMWB, you would need to
suspend the GPS, otherwise the GPS will sequence to the
next waypoint. True or false?
(a) True.
(b) False.
Now crossing YRMWF, the GPS sequences to YRMWM and
you continue descent to M.D.A. You observe the groundspeed
is higher than expected and thus determine there is a westerly
component wind of 15kt.
10. What is your M.D.A going to be and how will you join the
circuit when visual?
You now have the GPS sequencing, crossing YRMWB at 3900ft
and establishing on a track of 087º.
(a) 660ft, straight in runway 09.
8.
(c) 710ft, break left to join a right downwind for runway 27.
What distance readout will you see and to what height may
you now descend?
(b) 710ft, break right to join a left downwind for runway 27.
(d) 660ft, break right to join a left downwind for runway 27.
(a) 15 miles to YRMWM and 3500ft.
(b) 12.5 miles to YRMWM and 2700ft.
(c) 5 miles to YRMWI and 2700ft.
(d) 5 miles to YRMWI and 3500ft.
Now crossing YRMWI, you may descend to not below 2100ft.
9.
What distance readout will you see to enable the descent
to 1600ft or to cross check the 3º profile height of 2430ft?
69
(a) 7 miles to YRMWM.
(b) 5 miles to YRMWF.
(c) 3 miles from YRMWI.
(d) 2 miles to YRMWF.
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FLYING OPS
MAINTENANCE
IFR OPERATIONS
1. a. GEN 3.6.6
2. b. this consideration is uniquely
important in operating such
engines.
3. a. at some altitudes they may
cross over.
4. c.
5. c. can be verified from power
setting tables.
6. c. CASR Part 139; Certified
aerodromes have the more
stringent requirements.
7. a. closing the waste gate diverts
more exhaust flow through the
turbine.
8. a. ENR 1.4.2.
9. c. ENR 1.6 . 6.4
10. d. the internet briefing service
will only be available via
NAIPS after April 2012.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
1.
2.
3.
4.
c.
d.
a.
b.
5.
6.
7.
8.
c.
c.
a.
d.
a.
b.
a.
d.
c.
d.
b.
b.
c.
d.
AIP GEN 3.3 -17 Para 4.9
AIP GEN 3.3 -17 Para 4.8
AIP GEN 1.5 -16 Para 8.5.5.3
Relevant GNSS unit handbook.
Note the scaling change to approach
‘active’ occurs past the intermediate fix
with RAIM available.
AIP ENR 1.5 -14 Para 2.2.1
AIP ENR 1.5 -24 Para 3.3.4
Relevant GNSS unit handbook.
YYRM Rwy 09 approach plate.
Note, because the GNSS unit can only
show the distance to the next waypoint
and not total distance, it is very
important that if there are intermediate
descents between the waypoints, such
as this one at YRM, you must have
prepared what you expect to see as a
distance for that intermediate descent.
9. d.
10. b. YYRM Rwy 09 approach plate.
Note that the westerly wind means
circling for Rwy 27 and there is a
no circling restriction to the north
of the field.
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CALLSIGN
PARAFIELD
ETD
TAS
TYPE
SARTIME
WIND
UTC
LOCAL
CENSAR 1800 814 931
Standing personal minimums checklist
TAFS
ARFORS
(Review every 100 hours, or annually, or on completion of new rating/endorsement)
Endorsement, training & experience summary
JANDAKOT
S
VISUAL PILOT GUIDE 2010
ELEV 55
RN APRON
ELEV 31
NORTHE
CAMDEN
Compass
Swing Bay
C1
RO
N
ELEV 35
RA
L AP
BANKSTOWN
D1
NT
Key
Run-up bay
TWR
Intermediate holding position
Runway holding position
Runway incursion hotspot
F1
Apron grass area
E1
ELEV 94
C2
C3
ELEV 35
E2
E3 ELEV 39
Taxiway crossing (pedestrian)
N
ROUnsealed Taxiway
F2
RN
HE
UT
SO
AP
TWR
G1
F3
G3
Manoeuvring area
Aircraft
parking
ELEV 94
Terminal
TWR
An area on the aerodrome intended to accommodate aircraft for the purpose
of loading or unloading passengers, cargo, fuelling, parking, or maintenance.
That part of the aerodrome to be used for take-off, landing and taxiing
Helicopter
of aircraft, excluding aprons.
Training
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft,Area
consisting of the manoeuvring area and the aprons.
VISUAL PILOT GUIDE 2010
Aircraft
Key
ELEV 95
parking
Aircraft
Run-up bay
parking
NDB
Operation on the aerodrome
Intermediate holding position
281
Apron area – no taxi clearance required. Monitor Ground on 119.9 MHz.
Runway holding position
Taxiway – taxi clearance from Ground required before entering this area.
Runway incursion hotspot
Toll facility
Runway – specific clearance required from ATC
before94entering this area.
ELEV
Key
Definitions
Revised
self-assessment
Maximum crosswind as % of pilot’s operating
handbook figure for type
Minimum runway requirement as % of pilot’s
operating handbook figure for type
Minimum visibility – day VFR
Minimum visibility – night VFR
Minimum ceiling – day VFR
Minimum ceiling – night VFR
Surface wind speed & gusts
Maximum cross wind
Other VFR (eg: mountain flying,
over water beyond gliding distance)
Fuel reserves (day VFR)
Fuel reserves (night VFR)
NOTAM
POSN
NAV/COMM LOG
TR (m) HDG (m) G/S DIST ETI EST
Left tank
Minutes
Gauge each tank
Example:
100 hour VFR pilot
50%
150%
12km
15km
3,000 feet
5,000 feet
15 knots 5 knot gust
7 knots
Consult instructor/
mentor
1 hour
1½ hours
Your personal
minimums
Right tank
Time
LOCATION
FIR
HEAD OFFICE
ALT
Time
Minutes
each tank Gauge
180
180
150
150
120
120
90
90
60
60
ATA ATD
FUEL
(mins)
NAV/COM FREQ
FLIGHT
TAXI
*FIXED RES (45)
*VRB RES
ALTN
HOLDING INTER (30)
TEMPO (60)
TOTAL FUEL
* Recommended
VFR LEVELS
30
30
PILOT NOTES ________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
359
EVENS
+
500
180
www.casa.gov.au | p.131 757
Run-up
bay
1108.1571
P
Apron
area
An area on the aerodrome intended to accommodate aircraft for the purpose
Intermediateof holding
positionpassengers, cargo, fuelling, parking, or maintenance.
loading or unloading
Runway
position
Manoeuvring
area holding
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft, excluding aprons.
Movement area
Definitions
Apron area
Manoeuvring area
1108.1571 J
Movement
area
Key
Run-up bay
Intermediate holding position
Runway holding position
Runway incursion hotspot
Operation on the aerodrome
Definitions
Apron area
Manoeuvring area
1108.1571 C
Movement area
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft, consisting of the manoeuvring area and the aprons.
An area on the aerodrome intended to accommodate aircraft for the purpose
Operation
on thepassengers,
aerodromecargo, fuelling, parking, or maintenance.
of loading
or unloading
Apron area – no taxi clearance required. Monitor Ground on 124.3 MHz.
That part of the aerodrome
for take-off,
landing
andbefore
taxiing
Taxiwayto– be
taxiused
clearance
from Ground
required
entering this area.
of aircraft, excluding Runway
aprons. – specific clearance required from ATC before entering this area.
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft, consisting of the manoeuvring area and the aprons.
Apron area – no taxi clearance required. Monitor Ground on 121.9 MHz.
Taxiway – taxi clearance from Ground required before entering this area.
Runway – specific clearance required from ATC before entering this area.
An area on the aerodrome intended to accommodate aircraft for the purpose
of loading or unloading passengers, cargo, fuelling, parking, or maintenance.
VISUAL
V
SU
PILOT
O GUIDE
GU
2010
0
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft, excluding aprons.
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft, consisting of the manoeuvring area and the aprons.
Operation on the aerodrome
Apron area – no taxi clearance required. Monitor Ground on 119.9 MHz.
Taxiway – taxi clearance from Ground required before entering this area.
Runway – specific clearance required from ATC before entering this area.
* please note that a postage and handling fee of $15 applies to each order
1108.1571 B
flightsafety
… essential aviation reading
INSIDE JAN - FEB 2012
What do you know? Safety management systems
The light fantastic: the promise and hazards of
composite materials
All present and correct: checklist use and design
And … more close calls
000
ODDS
+
500
179
1009.1351 (d)
Movement area
Aircraft
parking
VISUAL PILOT GUIDE 2010
Definitions
Apron area
G2
MELBOURNE BASIN
1108.1571 (c) v2
For these and many more other free* safety
promotion products visit the CASA online
store at www.casa.gov.au/onlinestore
Self-assessment
factors
Endorsement/ratings (eg: night VFR, MPPC)
Flight review
Time since last instruction in aircraft #1:
Time since last instruction in aircraft #2:
Time since last instruction in aircraft #3:
Familiarity with avionics/GPS
Experience
Total flying time in hours
Number of years flying
Hours in the last year
Hours in this or identical aircraft in last year
Landings in last year
Night hours in last year
Night landings in last year
High density altitude hours in last year
Mountainous terrain hours in last year
Strong crosswind or gusty landings in last year
Personal minimums
SYDNEY BASIN
TWR
CE
FSA NOV-DEC 2011
For more information and a full price list, contact Air South
on (08) 8234 3244 or visit www.airsouth.com.au
| Archerfield | Bankstown | Cairns | Cambridge | Camden | Jandakot | Launceston | Moorabbin | Parafield |
Online
in flight
flig
gh planning
ning for Australian aviation
Your interactive guide to operations
Y
in and around controlled airspace
www.casa.gov.au/ontrack
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